ORLANDO—Computed tomography (CT) scanning and blood tests to determine tumor markers are very important in the follow-up of stage I nonseminomatous testicular cancer (NSTC), but the physical examination is of limited value, according to new research presented in a poster session.
“To be quite frank, I’ve done the physical examination of these nonseminomatous stage I patients about 1800 times and my colleague has done 700 such exams, and rarely have we found anything. At some point, we began to talk and ask each other if we’d seen anything yet, and we began to wonder if the physical exam was worth it,” Kees Meijer, RN, MS, MA, nurse practitioner in the department of surgical oncology at University Medical Center Groningen, the Nether lands, told The Oncology Nurse-APN/PA.
After orchiectomy, most patients (70%) appear to be free of metastases. Deemed to have stage I disease, they are started on an intensive “wait-and-see” regimen that includes 25 outpatient visits in 5 years, 18 of which occur in the first 24 months. At each visit, patients have a blood test to determine tumor markers alpha-fetoprotein, beta-human chorionic gonadotropin, and lactate dehydrogenase. In the first year, they also undergo a CT scan of the chest and abdomen every 3 to 4 months, and this frequency is tapered in later months, so that in all, they undergo nine scans.
They also have a physical examination, which consists of palpation of the scrotum and remaining testis, locoregional and supraclavicular lymph nodes, and the abdomen, as well as a check for the presence of gynecomastia.
To assess the value of the physical examination, Meijer and his team retrospectively studied all stage I NSTC patients in follow-up from October 1999 to June 2010. During this time, 133 patients made a total of 2547 visits to the outpatient clinic. Of these, 104 patients remained free of disease and 29 (22%) developed metastatic disease.
In 16 patients, the recurrence was first detected by CT. Elevated tumor markers detected recurrence in 12 patients, one of whom also reported groin swelling. Only one patient was diagnosed with a recurrence on physical examination.
“It wasn’t even us who were the first to detect it. The patient noticed a swelling in his groin, and detected it himself, so on the whole we saw many patients and did many physical examinations with hardly any results,” Meijer noted.
Freeing these men from having to come to the clinic for useless examinations would be a distinct benefit to many of them, he added. Blood can be drawn by the patient’s family doctor or general practitioner, and then sent to the clinic. The only time a patient needs to visit in person is when the CT scan is due.
“There is no harm in doing the test, but there is inconvenience,” said Meijer. “The patient has to take time off work, drive here, which in our case can take up to 2 hours since we are in the north and many patients do not live close to the hospital, all for something which is not really useful. If you teach them well, you can keep them assured that if they don’t want to come in that often, they are still OK. It is a false reassurance they are getting every time I examine them and I say there is nothing.”