718: Modeling the Cost of Management Options for Stage I Nonseminomatous Germ Cell Tumors: A Decision Tree Analysis

Purpose Patients with clinical stage I nonseminomatous germ cell tumors (NSGCTs) have been managed with surveillance, chemotherapy, or retroperitoneal lymphadenectomy (RPLND) with similar survival outcomes. Cost factors influencing the choice of therapy were evaluated using computer-based decision analysis. Methods A detailed model was developed that integrates projected costs for more than 60 possible treatment outcomes. It incorporates primary, adjuvant, and salvage chemotherapy, primary and postchemotherapy RPLND, and both laparoscopic and open surgical approaches. Starting values and probabilities were derived from a comprehensive meta-analysis of the last 25 years of testes cancer literature. Hypothesis testing was performed using sensitivity analysis. Results The model predicts a cost premium for both primary chemotherapy (18.7%) and RPLND (51.7%) compared with surveillance. If laparoscopic RPLND was practiced, the cost premium for primary surgery (29.1%) approached that of chemotherapy (26.4%). Open RPLND was 1.25× as costly as laparoscopic RPLND, primarily because of longer hospitalization. The choice of open RPLND yielded a 6.9% cost premium for a surveillance program in this model. For such a program, primary chemotherapy became cost advantageous when the probability of recurrence during surveillance was more than 46%. Conclusion This model allows a variety of treatment cost hypotheses to be tested. Primary RPLND is never cost advantageous over surveillance or primary chemotherapy. Surgical costs can significantly increase the overall cost of a surveillance program. In stage I patients with high-risk tumor characteristics, primary chemotherapy may have a cost advantage over surveillance.

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Brain metastases during follow-up of children and adolescents with extracranial malignant germ cell tumors: Risk adapted management decision tree analysis based on data of the MAHO/MAKEI-registry

Pediatric Blood & Cancer ◽

10.1002/pbc.24229 ◽

2012 ◽

Vol 60 (2) ◽

pp. 217-223 ◽

Cited By ~ 5

Author(s):

Ulrich Göbel ◽

Rüdiger von Kries ◽

Carmen Teske ◽

Dominik T. Schneider ◽

Andreas Beyerlein ◽

...

Keyword(s):

Decision Tree ◽

Brain Metastases ◽

Germ Cell ◽

Children And Adolescents ◽

Germ Cell Tumors ◽

Management Decision ◽

Decision Tree Analysis ◽

Tree Analysis ◽

Malignant Germ Cell Tumors

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Immunohistochemical Expression of Ki-67 to Predict Lymph Node Involvement in Clinical Stage I Nonseminomatous Germ Cell Tumors

The Journal of Urology ◽

10.1016/s0022-5347(01)64571-3 ◽

1997 ◽

Vol 158 (2) ◽

pp. 620-625 ◽

Cited By ~ 10

Author(s):

Axel Heidenreich ◽

Noah S. Schenkmann ◽

Isabell A. Sesterhenn ◽

F. Kash Mostofi ◽

William F. McCarthy ◽

...

Keyword(s):

Lymph Node ◽

Germ Cell ◽

Clinical Stage ◽

Germ Cell Tumors ◽

Lymph Node Involvement ◽

Stage I ◽

Immunohistochemical Expression ◽

Ki 67 ◽

Node Involvement ◽

Nonseminomatous Germ Cell Tumors

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Treatment of Relapse of Clinical Stage I Nonseminomatous Germ Cell Tumors on Surveillance

Journal of Clinical Oncology ◽

10.1200/jco.18.01250 ◽

2019 ◽

Vol 37 (22) ◽

pp. 1919-1926 ◽

Cited By ~ 13

Author(s):

Robert J. Hamilton ◽

Madhur Nayan ◽

Lynn Anson-Cartwright ◽

Eshetu G. Atenafu ◽

Philippe L. Bedard ◽

...

Keyword(s):

Germ Cell ◽

Odds Ratio ◽

Clinical Stage ◽

Germ Cell Tumors ◽

Stage I ◽

Line Treatment ◽

First Line ◽

Factors Associated ◽

Nonseminomatous Germ Cell Tumors ◽

First Line Treatment

PURPOSE Active surveillance (AS) for testicular nonseminomatous germ cell tumors (NSGCT) is widely used. Although there is no consensus for optimal treatment at relapse on surveillance, globally patients typically receive chemotherapy. We describe treatment of relapses in our non–risk-adapted NSGCT AS cohort and highlight selective use of primary retroperitoneal lymph node dissection (RPLND). METHODS From December 1980 to December 2015, 580 patients with clinical stage I NSGCT were treated with AS, and 162 subsequently relapsed. First-line treatment was based on relapse site and extent. Logistic regression was used to explore factors associated with need for multimodal therapy on AS relapse. RESULTS Median time to relapse was 7.4 months. The majority of relapses were confined to the retroperitoneum (66%). After relapse, first-line treatment was chemotherapy for 95 (58.6%) and RPLND for 62 (38.3%), and five patients (3.1%) underwent other therapy. In 103 (65.6%), only one modality of treatment was required: chemotherapy only in 58 of 95 (61%) and RPLND only in 45 of 62 (73%). Factors associated with multimodal relapse therapy were larger node size (odds ratio, 2.68; P = .045) in patients undergoing chemotherapy and elevated tumor markers (odds ratio, 6.05; P = .008) in patients undergoing RPLND. When RPLND was performed with normal markers, 82% required no further treatment. Second relapse occurred in 30 of 162 patients (18.5%). With median follow-up of 7.6 years, there were five deaths (3.1% of AS relapses, but 0.8% of whole AS cohort) from NSGCT or treatment complications. CONCLUSION The retroperitoneum is the most common site of relapse in clinical stage I NSGCT on AS. Most are cured by single-modality treatment. RPLND should be considered for relapsed patients, especially those with disease limited to the retroperitoneum and normal markers, as an option to avoid chemotherapy.

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Prognostic risk factors that identify patients with clinical stage I nonseminomatous germ cell tumors at low risk and high risk for metastasis

Cancer ◽

10.1002/(sici)1097-0142(19980901)83:5<1002::aid-cncr27>3.0.co;2-a ◽

1998 ◽

Vol 83 (5) ◽

pp. 1002-1011 ◽

Cited By ~ 129

Author(s):

Axel Heidenreich ◽

Isabell A. Sesterhenn ◽

F. Kash Mostofi ◽

Judd W. Moul

Keyword(s):

Risk Factors ◽

High Risk ◽

Germ Cell ◽

Clinical Stage ◽

Germ Cell Tumors ◽

Low Risk ◽

Stage I ◽

Prognostic Risk Factors ◽

Nonseminomatous Germ Cell Tumors

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Short-course adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis: a Medical Research Council report.

Journal of Clinical Oncology ◽

10.1200/jco.1996.14.4.1106 ◽

1996 ◽

Vol 14 (4) ◽

pp. 1106-1113 ◽

Cited By ~ 238

Author(s):

M H Cullen ◽

S P Stenning ◽

M C Parkinson ◽

S D Fossa ◽

S B Kaye ◽

...

Keyword(s):

High Risk ◽

Adjuvant Chemotherapy ◽

Germ Cell ◽

Medical Research ◽

Research Council ◽

Medical Research Council ◽

Germ Cell Tumors ◽

Stage I ◽

Nonseminomatous Germ Cell Tumors

PURPOSE This United Kingdom Medical Research Council (UK-MRC) study prospectively evaluated efficacy and long-term toxicity of adjuvant chemotherapy in high-risk stage I nonseminomatous germ cell tumors of the testis (NSGCTT). PATIENTS AND METHODS Eligible patients were those identified by the local histopathologist as having features confirmed in MRC surveillance studies to indicate an approximate 50% risk of relapse. Central histopathology review was undertaken. Chemotherapy consisted of two courses of cisplatin 100 mg/m2, bleomycin 30 mg weekly x 3, and etoposide 120 mg/m2 x 3, every 21 days (BEP). RESULTS One hundred fourteen eligible cases were enrolled. Median time of follow-up was 4 years, with 93 patients followed-up for at least 2 years. There have been two relapses, including one patient who did not have a germ cell tumor (GCT), according to the reference histopathologist. This patient is alive with active disease, the other has died. There was one death after a cerebrovascular accident during treatment. Assessment of fertility, lung function, and audiometry pretreatment and more than 9 months posttreatment indicated no clinically significant changes. A mean decrease in transfer factor coefficient (KCO) of 15% of the predicted value was noted, but no patient had symptomatic respiratory dysfunction. CONCLUSION There have been only two relapses among 114 cases of high-risk stage I NSGCTT treated with two courses of adjuvant BEP chemotherapy. The 95% confidence interval (CI) excludes a true relapse rate of more than 5%. Of 104 patients confirmed on histopathology review to have GCT, there has been only one relapse. Adjuvant chemotherapy is free from significant long-term toxicity, offering an effective alternative to surveillance or retroperitoneal lymph node dissection (RPLND) followed by surveillance, and may be preferred by some patients.

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