How to followup patients

1
How to follow-up patients

• Professor Gordon Rustin
• Director of Medical Oncology
• Mount Vernon Cancer Centre
• Northwood
• UK

2
Why do we follow-up patients who have had germ
cell tumors?

• To detect relapse in the belief that earlier
  detection improves chance of cure
• To detect contralateral testis tumors
• To manage late toxicity
• For reassurance, support and counselling
• To collect data

3
First indication of relapse in TE08 stage I
surveillance trial
Rustin et al J Clin Oncol 25 1310-15, 2007
4
Characteristics of relapse following therapy for
germ cell tumour
Analysis of 96 relapses in 547 patients
achieving remission Median time to relapse 6
months (1-89), 85 within 18 months Elevated
markers 54 Retro-peritoneal nodes 58 Lung 26
Liver 15 CNS 8 Flechon et al European
Urology 48, 957-964 2005
5
Relapses gt 2 years after completion of therapy
for germ cell tumours
119 / 3704 (3.2 ) Nonseminoma 150 / 5880 (2.6 )
Seminoma 10-year cause-specific survival 68 in
all patients 50 in patients relapsing with vital
malignant tumour 100 in those with teratoma/
necrosis before or after salvage chemotherapy.
Oldenburg, Martin Fossa J Clin Oncol 24
5503-11, 2006
6
Localization of late relapsesOldenburg, Martin
Fossa J Clin Oncol 24 5503-11, 2006
Site Nonseminoma Seminoma Retroperitoneum 236
51 34 55 Mediastinum 43
9 17 27 Lung/Pleura 77 17 2
3 Neck/Supraclavicular 30 7
9 15 Pelvis 20 4 1 2 Other
53 12 3 5 AFP 207 49 HCG 100 24
7
Adapting frequency of follow-up investigations to
risk of relapse
Risk Nonseminoma Seminoma gt10 Monthly 3
monthly 5-10 2 monthly 4 monthly 1-5 3-4
monthly 6 monthly 0.3-1 6-12 monthly 12
monthly lt0.3 discharge unless
TD discharge or residual mass
8
ESMO Minimum Clinical Recommendations for
Follow-up of NSGCT stage 1 on surveillance
Clincal review, chest X-ray, and serum HCG AFP
monthly for 1 year 2 monthly for 2nd year, 4
monthly 3rd year, 6 monthly year 4 to 8 CT scans
after 3 and 12 months Huddart RA, Ann Oncol 18
suppl 2, ii42-ii43, 2007
9
ESMO Minimum Clinical Recommendations for
Follow-up of NSGCT after chemotherapy
Clinical review, chest X-ray, and HCG AFP 2
monthly for 1 year, 3 monthly for 2nd year 6
monthly to 5 years then annually CT scans only as
clinically indicated Huddart RA, Ann Oncol 18
suppl 2, ii42-ii43, 2007
10
Royal Marsden Minimum Clinical Recommendations
for Follow-up for stage 1 seminoma on surveillance
Clincal review and serum HCG, AFP LDH 3 monthly
for 2 years 4 monthly for 3rd year, 6 monthly
year 5 and 6 12 monthly years 6-10 Chest X-ray
alternate visits for 2 years then annually to 5
years CT scans abdomen only unless pelvis at high
risk at 6, 12, 18, 24, 36, 48, and 60 months Van
As et al BJC 2008
11
ESMO Minimum Clinical Recommendations for
Follow-up for stage 1 seminoma after adjuvant
therapy
Chest X-ray and clinical examination at 1 month,
Then three monthly for 2 years Then 6 monthly to
5 years Pelvic CT in patients treated by
paraaortic strip (and abdominal CT in patients
treated by carboplatin) at year 1,2 and
5 Huddart RA Ann Oncol 18, Suppl2 ii40-ii41,
2007
12
ESMO Minimum Clinical Recommendations for
Follow-up of seminoma after metastatic disease
If normal CT scan follow-up as for stage 1 If
abnormal post-treatment CT scan repeat CT scan
every 6 months until normal or abnormalities
stabilised A PET scan may help identify residual
active cancer Consider biopsy or resection for
large residual or growing masses Huddart RA Ann
Oncol 18, Suppl2 ii40-ii41, 2007
13
Risks of excess CT scans

• Typical chest CT has an associated radiation dose
  equivalent to 400 chest X-rays (8 vs 0.02 mSv)
  (Royal College of Radiologists, 1998)
• Whole trunk CT produces dose of 10 to 30 mSv
• Typical whole trunk CT scan associated with a
  11000 risk of cancer/leukaemia

14
Definitions of Metabolic Syndrome
NCEP definition Norwegian definition At least 3
of At least 2 of BP gt 130/85 or
medication BP gt 140/90 or medication Waist
circum gt 102 BMI gt 30 Fasting glucose gt 5.6
mmol/l Self reported diabetes /
medication Triglycerides gt1.7 mmol/l Cholesterol
gt 5.2 mmol/l or medication HDL cholesterol
lt 1.0 mmol/l
15
Investigations to be performed at 2, 5 and 10
years to detect late effects of therapy for germ
cell tumors
Blood pressure Creatinine Fasting cholesterol,
HDL, LDL , triglycerides and glucose FSH, LH and
testosterone ? Hip examination ? Osteoporosis
screen
16
Questions related to follow-up of patients with
germ cell

• How many different follow-up schedules should be
  running?
• Could follow-up be nurse led?
• Is AFP necessary if pure seminoma?
• Is LDH of value in follow-up?
• Is Chest X-Ray necessary if no lung metastases
  at time of treatment for metastases?

17
LDH should not be measured routinely in follow-up
of germ cell tumours
125 of 494 stage I patients had elevated LDH at
relapse but in no case was it the first or only
sign of relapse Ackers Rustin BJC 94 1231-2,
2006 499 patients on surveillance or follow
up 26 of 1777 samples (1.4) true positive, 137
(7.7) false positive Only elevated marker at
relapse in 1 of 15 relapses. Contributed to
relapse detection in 4 of 35 (11)
seminomas Venkitaraman et al BJU Int 100 30-32,
2007
18
Malignant teratoma 32 years after treatment of
germ cell tumor confined to testis.Pavic M,
Meeus P, Treilleux I, Droz JP. Urology. 2006
Apr67(4)846
Is this the latest relapse after treatment of a
germ cell tumour?
19
How should we organise our follow-up to detect
the rare very late relapse?
Relapse after 10 years is seen in lt 1 of germ
cell patients These patients can be cured by
treatment that usually includes surgery Patients
should be warned about late relapse but their
rarity should not lead to prolonged follow-up