Testicular Cancer Treatment May Not Require Radiation
Chemotherapy, radiation and the use of radioactive follow-up tests aren’t needed for some cancers, according to two studies that add to a growing debate on ways to lessen side effects and lower patient costs.
One study, in 1,800 men, found that chemo or radiation immediately following surgery in testicular cancer made no difference in long-term survival. A second, in 537 patients, determined that patients treated for the most common kind of lymphoma aren’t helped by expensive surveillance scans afterward that use radioactive tracers.
The two findings were released in advance of the American Society of Clinical Oncology’s annual meeting in Chicago, set to begin May 31. They are the latest among recent studies aiming to fine-tune cancer care to eliminate the hair loss, fatigue, nausea and damaged DNA tied to the therapy while suggesting new ways to slow rising costs.
“The economics of health care and the quality of care are really being looked at more closely than in the past,” said Phil Kantoff, a professor of medicine at Harvard Medical School in Boston. “Why are you doing this? If the answer is ‘that’s what we do,’ rather than ‘there’s a study that shows we save lives this way,’ that’s not good.”
Researchers have been examining conventional treatment methods for some types of cancers to see whether the benefits are worth the complications that arise from the therapies themselves. Last year, for instance, prostate cancer testing used by half of men older than 40 was scrutinized in a U.S. Preventive Services Task Force report that said the screening isn’t worth the risk of side effects from unneeded treatment and shouldn’t be used to diagnose the disease.
Other tests that aren’t useful are repeated PET or CT scans to follow women in remission from early-stage breast cancer to make sure it is cured, according to the American Society of Clinical Oncology. Routine scans in such women without symptoms have no benefit, expose women to unnecessary radiation, and may create false-positive results that lead to unnecessary invasive procedures, the group says.
Cost reduction is also important, researchers have said. Cancer patients are 2.6 times more likely to file for bankruptcy, compared with people the same age without the disease, according to a study published this month in the policy journal Health Affairs. The researchers used bankruptcy court data from the state of Washington from 1995 to 2009.
The study in early-stage testicular cancer, reviewed the progress of patients over 10 years. It found that 99.6 percent of those who didn’t undergo radiation or chemo immediately after surgery were alive at the end of that period.
About 20 percent of patients had a relapse of cancer within a year. In the next two to five years, 4 percent had a relapse, and 1.4 percent of patients had a relapse more than five years after initial treatment, according to the report.
Initial treatment is to remove the testicle and the spermatic cord. After that, many doctors opt to treat patients with radiation or chemotherapy. Instead, doctors should consider simple surveillance as the preferred option of managing patients, according to the researchers, led by Mette Saksoe Mortensen of Copenhagen University Hospital in Denmark.
The Denmark study reinforces that not all patients need intense added care, said Len Lichtenfeld, the deputy chief medical officer for the American Cancer Society, in a telephone interview. The type of cancer in the study, called seminoma, is particularly responsive to surgery, he said.
The lymphoma study found that the most common kind of lymphoma isn’t helped by surveillance scans afterward, as the bulk of relapses are detected when symptoms arise and happen outside follow-up doctors’ visits. Use of radioactive tracers picked up by a scanner to look for disease after treatment found a recurrence in only eight of 537 patients, the study found.
Of the 537 patients who entered post-treatment observation, 20 percent relapsed and 41 died of other causes. In those who relapsed, 62 percent saw their physician earlier than a scheduled follow-up visit due to symptoms.
The disease, diffuse large B-cell lymphoma, is aggressive, and the best follow-up strategy after treatment isn’t clear, wrote the study authors, led by Carrie A. Thompson at the Mayo Clinic in Rochester, Minnesota. While previous research found that patients received a median of 2.5 scans a year, today’s study showed the schedule added little to relapse detection.
While the radioactive dye from CT scans can reveal hidden cancer, they also can damage DNA and show abnormal results for benign findings, spurring unneeded tests that may add additional risk, according to the U.S. Food and Drug Administration. They are priced at $1,033 each, according to the Health-Care Blue Book, which collects data on what insurers pay for services.
The dosage of radiation from CT scans varies, depending on what body part is being examined and the type of scanner. A single screening with an effective dose of 10 millisieverts may increase the possibility of fatal cancer to 1 in 2,000, the FDA has said. CT scans can cost up to 10 times as much as a standard x-ray, according to the American Cancer Society.
“The question is, do we treat 100 percent to save 20 percent?” said Timothy Eberlein, director of the Siteman Cancer Center at Barnes-Jewish Hospital and Washington University School of Medicine in St. Louis, in a telephone interview. “And so we over treat.”
That’s beginning to change as new research pinpoints when added treatment and testing may be necessary and, increasingly, identifies new genetic markers showing which targeted treatments will work best in patients and eliminating ineffective treatment, he said in a telephone interview.
More genetic markers for which patients require aggressive care are being discovered through the Cancer Genome Atlas Project, a U.S. National Institutes of Health effort to discover what changes make a normal cell cancerous and pinpoint more effective treatments. The group is examining 20 types of cancer to understand key mutations.
“When I was trained, 25-30 years ago, we were lumpers,” Eberlein said. “Every woman who had breast cancer had a mastectomy and every man who had a prostate cancer had a radical open prostatectomy, and there was no discussion of alternatives or other treatments. Move the clock forward, and we now have information that says, gee, we don’t need to be nearly as aggressive as we thought we did.”
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