C all tumors in males and have ranged from the second

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1 National Survey of Patterns of Care for Testis Cancer B. J. KENNEDY, MD, JOSEPH D. SCHMDT, MD, DAVD P. WNCHESTER, MD, BARBARA L. PEACE, RRA, NATCHMUTHU NATARAJAN, MS, AND CURTS METTLN, PHD A national survey of testicular cancer documented recent trends in disease characteristics, treatment, and outcome, providing a basis for progress being achieved on a community basis. A long-term study of 3285 patients diagnosed between 1970 and 1975 was compared with a short-term study of 1887 patients diagnosed in An increase of the symptom of a lump in the testis from 23.1% to 31.2% and a mass as a sign of cancer from 44.5% to 53.8% suggests earlier detection of testis cancer by the patient and physician. Changes in the methods of diagnosis reflect the changing technology of tumor diagnosis. The 10-year survival rates for pathologic Stage seminoma (82.6% of all seminomas) exceeded 96%. For pathologic Stage nonseminomatous germ cell tumors (51.7% of all NSCCr), 10-year survival was 87.1%; whereas for Stage 111 (18.7% of all NSCCr) it was 22.1%. The impact of the important advances in chemotherapy is reflected in the increase of -year survival of Stage 111 NSCCT from 50.5% to 78.4%. Testis cancer can be cured in most patients. Cuncer 60: , ARCNOMAS OF THE TESTS COnStitUte 1% to 2% Of C all tumors in males and have ranged from the second to the fourth leading cause of cancer deaths in male subjects between the ages of in the US. mprovements in radiographic techniques and the advent of serologic markers for testis cancer have greatly advanced the accuracy of noninvasive staging of testis cancer compared with a decade ago. Further, advances in the therapy of testis tumors have led to a remarkable improvement in survival rates for all stages of disease. Few data document those management and end result trends across the broad spectrum of cancer-care facilities, where a significant proportion of testicular cancer patients are diagnosed, treated, and followed. The Commission on Cancer of the American College of Surgeons (ACOS) has conducted national surveys on the diagnosis and treatment of cancer involving tumors of the liver, carcinoma of the colon and rectum, prostate, breast, uterine cervix, melanoma of skin, endometrium, Hodglun s disease, and soft-tissue sarcoma. n 1985, studies concerning trends in testicular cancer management and outcome were conducted. The results of the studies are reported and are intended to document recent trends in patient, disease, and treatment characteristics related to testicular cancer. The data presented From the Commission on Cancer of the American College of Surgeons, Chicago. llinois. Supported in part by Grant PDT- 90D from the Amencan Cancer Society. Address for reprints: Commission on Cancer, American College of Surgeons, 55 East Erie Street, Chicago, L Accepted for publication August, on end results also may provide some basis for assessing the progress being achieved on a widespread basis in the control of this disease. Methods n 1984, the cancer committees of hospitals participating in the ACOS approval program were invited to contribute to a study in testis cancer and were provided survey forms and instructions. The forms were developed and pretested by a subcommittee of the Patient Care and Research Committee of the Commission on Cancer. The long-term study requested entry of up to 25 patients who initially were diagnosed and received all or any part of their initial work-up and treatment at the reporting hospital prior to December 3 1, This date was selected to permit evaluation of outcomes of patients diagnosed prior to the widespread impact of improved chemotherapy. Patients whose diagnostic evaluation and initial treatment were begun but not completed in that period were also included. The hospitals were requested not to go back further than January 1, 1970, for the cases. n the short-term study, data were requested on up to 25 patients who initially were diagnosed with histologically confirmed cancer of the testis and received all, or any part, of their initial work-up and treatment at the reporting hospital from January 1, 1983 through December 3 1, Patients whose diagnostic evaluation and initial treatment were begun, but not completed, in that period also were included. Patients diagnosed histologically, but who received no cancer-directed treat- 1921

2 1922 CANCER October Vol bo ACOS e-o SEER All reports were reviewed by the participating cancer committees before submission. The data were then submitted to the Cancer Department of the ACOS and subsequently to Roswell Park Memorial nstitute, (Buffalo, NY), for analyses. The cancer-specific survival rates were calculated using the Kaplan-Meier actuarial methods.2 The test for significance of the difference between proportions is based on the chi-square test. Age at Diagnosis RG.. Age distribution of testis cancer patients from the ACOS compared with SEER data of the National Cancer nstitute. ment, were included, since for the purposes of this study no treatment arbitrarily was considered a treatment category. Patients diagnosed only by autopsy were excluded. Planned combined treatment modalities of any type started during the four-month period from the date of diagnosis were to be interpreted as part of the initial treatment. Age at Diagnosis M Seminoma H Non-Seminoma RG. 2. Age distribution of testis cancer patients by histologic condition. Results Three hundred ninety-seven hospitals volunteered reports on 3285 patients in the long-term study, and 519 hospitals reported on 1887 patients in the short-term study. n the long-term survey, 24.4% of the patients were diagnosed initially in 1975, and the remainder were diagnosed between 1970 and Hospitals that participated were widely distributed geographically. n the long-term study, reports were received from 44 states, and Puerto Rico. n the short-term study, hospitals in 49 states, Puerto Rico, and the District of Columbia participated. Age at Diagnosis The age at diagnosis for patients reported in the longterm study ( ) was compared with the age distribution of the patients from the Surveillance, Epidemiology, and End Results (SEER) report for the period 1973 to (Fig. 1). Except for the slight shift in the period of diagnosis, the curves are identical. The median age of patients was 3 1 years; the same as that reported as the national pattern by SEER. Comparison of the age distribution by histologic condition showed that nonseminoma or mixed histology patients were significantly younger than patients with seminoma only (Fig. 2). The median age for patients with nonseminoma was 25 years and 38 years for patients with seminoma. Race Distribution n the long-term study, 90% of the patients were white, 6.6% black, and 2.3% other races. For 1.1 %, race was unknown. n the short-term study 89% of the patients were white, 6.7% were black, and 3.2% were other races. For 1.2%, race was unknown. According to the 1980 US census, the race distribution of US male population was 83.3% white, 11.4% black, and 5.3% other race or race unknown. The lesser representation of blacks in these data relative to census figures reflects the epidemiologic observations of others that blacks are at lesser risk of testis cancer than white^.^ Reason for Hospital Admission n the long-term study, 67.0% of the patients reportedly discovered the testicular mass themselves com-

3 No. 8 PATTERNS OF TESTS CANCER CARE Kennedy et al TABLE 1. Medical History: Reason for Admission TABLE 2. Symptoms for Testicular Cancer Reason for admission No. Percent No. Percent Testicular mass discovered by Patient Physician Other O Not specified Admission not related to testis Unknown Total pared to 70.0% of the patients in the short-term study. Testicular mass was discovered by the physician in 15.2% of the long-term and 14.8% of the short-term patients. n 3.5% of the long-term study patients and 4.3% of the short-term study patients, the purpose of admission was not related to the testis (Table 1). Laterulity of nvolved Testis The results from both studies show more frequent diagnosis of right testis tumors than left. n the longterm survey 52.1% of the patients were with involved right testis, 45.0% with involved left testis, 0.3% with bilateral involvement and in 2.6% laterality was not specified. The results of the short-term study also were similar where 53.5% were with right testis tumors, 43.6% were with left testis tumors, 0.4% with bilateral involvement and 2.5% with unspecified site. History of Cryptorchidism and History of mpaired Fertility n the long-term study, 7.9% of the patients had a history of cryptorchidism and in the short-term study, 9. % of patients were reported as having such a history. History of impaired fertility was reported in 2.2% of the long-term study and 3.4% of the short-term study. Symptoms at Time oj-diugnosis The most common symptom at time of diagnosis was swollen or enlarged testis, which occurred in 6 1.2% of the patients in the long-term data and 56.4% of patients in the short-term data. Painful testis and lump in the testis also commonly were reported. There was an 8% increase in the report of lump in the testis between the long- and short-term study. Little change is evident in the other reported symptoms at the time of diagnosis between the long-term and short-term data (Table 2). Signsfor Testicular Cancer Enlarged testis was the sign most frequently reported in the diagnosis of testicular cancer followed by mass in Symptoms No. Percent* No. Percent* None Swollen or enlarged testis Painful testis Lump in testis History of recent trauma Tender or enlarged breasts Back pain Abdominal pain Weight loss Other masses cough Shortness of breath Other Not stated * Total exceeds 100% due to multiple reported symptoms the testis and tender testis (Table 3). Mass in the testis was the sign reported in 44.5% of the long-term and 53.8% of the short-term study (P < 0.01). Modes of Diagnosis Several diagnostic tests were reported as performed on patients with testis cancer (Table 4). Some changes were observed in the patterns of testing between the time of the long-term survey and the more recent data. Although they were performed less often, the highest incidence of positive results was associated with testicular ultrasound and abdominal ultrasound. n the short-term study, 14.4% of patients received testicular ultrasound of which 78.8% had positive results. Likewise in the shortterm data, 6.9% of patients received abdominal ultrasound and a positive result was observed in 46.6%. The use of serum lactate dehydrogenase, serum alkaline phosphatase, serum alphafetoprotein, serum chorionic gonadotropin, computed axial tomography (CAT) TABLE 3. Signs for Testicular Cancer Signs No. Percent No. Percent Enlarged testis (swollen) Mass in testis Tender testis Firm testis Abdominal mass Weight loss Gy necomastia nguinal nodes enlarged Supraclavicular nodes enlarged Hepatomegaly Other Not stated

4 1924 CANCER October Vol. 60 TABLE 4. Modes of Diagnosis in Patients With Testicular Cancer TABLE 6. Histopathology of Testicular Cancer Percent Percent elevated/ elevated/ Percent positive Percent positive Laboratory studies done results* done results* LDH Serum alkaline p hosphatase Serum alphafetoprotein Serum chorionic gonadotropin Urinary chorionic gonadotropin Chest x-ray Lung tomography CAT Scan. lung VP Lymphogram, pedal Liver nuclide scan Abdominal ultrasound CATscan, abdomen Venacavogram Scrota1 transillumination Testicular ultrasound Bone nuclide scan Brain nuclide scan LDH: lactate dehydrogenase; CAT: computed axial tomography VP: intravenous pyelography (excretory urography). *Percentages of positive results are for patients on whom the study was performed. for lung and CAT for abdomen increased significantly from the long-term study to the short-term study. The rate of elevated or positive results also increased in most of these studies from the long-term to the short-term study. TABLE 5. Postorchiectomy Evaluations Performed in Patients With Testicular Cancer Percent Percent Evaluation > 2 weeks Percent elevated Percent elevated after orchiectomy done results; done results* LDH Serum alphafetoprotein Serum chorionic gonadotropin Urinary chorionic gonadotropin LDH: lactate dehydrogenase. * Percentages of elevated results are for patients on whom the test was performed more than 2 weeks after orchiectomy. Histologic type No. Percent No. Percent Seminoma Embryonal carcinoma Teratocarcinoma Teratoma Choriocarcinoma Yolk-sac tumor Seminoma + embryonal carcinoma Seminoma + teratoma Seminoma + teratocarcinoma Seminoma + embryonal carcinoma + teratoma Embryonal carcinoma + yolk-sac tumor Teratocarcinoma + yolk-sac tumor Choriocarcinoma + other combination* Unknown o Total * Embryonal, seminoma, seminoma + embryonal, teratocarcinoma, embryonal + teratocarcinoma, seminoma + teratocarcinoma, seminoma + embryonal + teratocarcinoma, teratoma, embryonal + teratoma, seminoma + teratoma, seminoma + embryonal t teratoma. The use of urinary chorionic gonadotropin decreased from 32.0% in the long-term study to 7.6% in the shortterm study; however, the rate of elevated results did not change significantly for this study. The use of excretory urography, liver nuclide scan, lymphogram, and venacavogram also decreased significantly from the longterm to the short-term study. Studies After Orchiectomy Serum lactate dehydrogenase, serum alphafetoprotein, and serum chorionic gonadotropin increasingly were used after orchiectomy (i.e., >2 weeks) markers in the recent short-term study compared to the long-term study. Urinary chorionic gonadotropin was used in 4.4% of the patients in the short-term study (Table 5). Histoogic Type Seminoma is the most common testicular neoplasm, accounting for 50% of the patients in the long-term study and 52% in the short-term study (Table 6). Embryonal carcinoma accounted for 17.4% of the longterm study and 17.0% of the short-term study. Teratocarcinoma was reported in 12.1% of patients in the long-term and 9.2% in the short-term study. Choriocarcinoma, which is uncommon in its pure form, was reported in 1.5% of the long-term study patients and 0.7% of the short-term study patients. Seminoma mixed with

5 No. 8 PATTERNS OF TESTS CANCER CARE - Kennedy et al other tumor elements occurred in 13.7% of the patients in the long-term study and 10.1 % of the patients in the short-term study. A mixed histologic condition occurred in 465 (14.2%) of the long-term patients and in 282 (14.9%) of short-term patients. Stage Distribution nformation on the extent of disease at the time of diagnosis was requested for three methods of clinical and pathologic staging. Method 1 was that of the traditional urologic staging system, Method 2 was that employed by the NH Testicular Cancer ntergroup Study, and Method 3 was that of the American Joint Committee on Cancer (AJCC). Both clinical and pathologic staging were considered. This survey gave an opportunity to evaluate the effectiveness and extent of use of these staging systems. The results of these evaluations are to be reported in detail elsewhere. n brief, the AJCC method stage was reported less often, suggesting that data for that method were lacking in records. The survival curves for AJCC clinical staging were uninformative. The trends in the other two systems were similar. For purposes of the current report, Method 2 (NH Testicular Cancer ntergroup) was used (Table 7). Clinical Stage n the ntergroup staging, the stages are, 1 and 111. Stages 1 and 11 have been subdivided into 11-N 1,-N2, 11-N3, LN4, and A, B, C. There were no clinical staging data supplied on 41.9% of the long-term and 39.7% of the short-term study patients. n addition, the clinical stage was unknown in 5.9% and 5.2%, respectively. The distributions of clinical stages were known in 52.2 and 55.1% of the two studies. Of these, nearly 68% of the patients in both studies had clinical Stage disease (Table 8). Stage 11-N 1 disease is not assessable clinically, since this represents microscopic disease in the nodes. Pathologic Stuge Proportions of patients with no response or unknown on pathologic stage were 35% in long-term and 32.3% in the short-term study. The greater increase in reporting pathologic staging (65% and 67.7%, respectively) suggests that there were more patients with information on pathologic staging than with clinical stage in this method (Table 8). The pathologic stage distributions between the longterm study and the short-term study were similar. Stage disease was reported in 66.3% and 64.3% of the patients, respectively. Stage and Histology Seminoma patients had a significantly higher proportion of clinical Stage disease than nonseminoma pa- Stage 11-N 1 1-N2 -N3 -N4 A B C TABLE 7. Staging System: Method 2 (ntergroup) Extent of tumor Tumor confined to testis Microscopic involvement of lymph nodes only Lymph nodes enlarged, no extension beyond nodes Massive retroperitoneal lymph node involvement or extension into adjacent areolar tissue but without evidence of spread above diaphragm or to solid visceral organs, all disease removed at surgery As above, residual disease remains after surgery Supraclavicular node involvement only Metastatic tumor above diaphragm or to solid visceral organs, brain or bone. Specific sit&) Persistent elevated HCG or AFP after retroperitoneal lymphadenectomy tients (Table 9). Also nonseminoma patients had four times more clinical Stage 11 patients in the long-term study and seven times more Stage 11 patients in the short-term study compared to the seminoma group. Similar ratios were evident in the pathologic stage data. Treatment Treatment for testis cancer is determined by the clinical stage. Hence, analysis of the methods of initial treatment was undertaken for this method of staging. Treatment of seminoma patients by clinical stage: There was no change in the treatment of Stage patients TABLE 8. Extent of Disease (Stage) at Time of Diagnosis: Clinical and Pathologic Stage's* Stage No. Percent No. Percent Clinical 11-N 1 -(NA) -N2 -N3 -N4 111-A H-B 111-c Total Pathologic 11-N -N2 -N3 -N4 A B C Total NA: not assessable. * Method o

6 1926 CANCER October Vol. 60 TABLE 9. Clinical and Pathologic Stages Stage Total Histologic condition No. Percent No. Percent No. Percent No. Percent Clinical stage* Seminoma Nonseminoma Total Seminoma Nonseminoma Total Pathologic stage* Seminoma Nonseminoma Total Seminoma Nonseminoma Total * Unknowns not tabulated. between the long-term study and short-term study (Table 10). n this group, 90.8% of the long-term study patients and 90.4% of the short-term study patients were treated by surgery and radiation. For Stage 1 patients, although the numbers are small, there appears to have been a slight decrease in the use of surgery and radiation in the short-term study and a corresponding increase in the treatment by surgery and chemotherapy. For Stage 111 patients, surgery and radiation use decreased from 62.2% in the long-term study to 15.8% in TABLE 10. Treatment for Seminoma Patients by Clinical Stage Clinical stage Total Treatment No. Percent No. Percent No. Percent No. Percent Surg only RT or CXT Surg RT Surg CXT Surg + RT + CXT None Total 615 OO OO Surg only RT or CXT Surg RT Surg CXT Surg + Rad + CXT None Total Surg: orchiectomy or orchiectomy + retroperitoneal lymphadenectomy; RT: radiation therapy; CXT: chemotherapy.

7 No. 8 PATTERNS OF TESTS CANCER CARE - Kennedy et al TABLE 1 1. Treatment for Nonseminomatous Germ Cell Tumors by Clinical Stage Clinical stage Total Treatment No. Percent No. Percent No. Percent No. Percent Surg only RT or CXT o Surg + RT Surg t CXT Surg + RT + CXT None Total Surg only RT or CXT Surg + RT o Surg t CXT Surg + RT + CXT None Total * Surg: orchiectomy or orchiectomy + retroperitoneal lymphadenectomy; RT: radiation therapy; CXT chemotherapy. the short-term study and the use of surgery and chemotherapy use increased from 0% in the long-term to 57.9% in the short-term study. Trcatment of nonseminoma patients by clinical stage: n the treatment pattern for clinical Stage disease patients, there was a significant increase in the use of surgery only in the short-term study compared to the longterm study (Table 11). For Stage 1 patients in the longterm study, surgery plus radiation and surgery plus chemotherapy were equally employed; but in the shortterm study, surgery and chemotherapy was used on most of the patients. Even in the Stage 11 patients, there was an increase in the use of surgery and chemotherapy between the long-term study and short-term study, and less use of radiotherapy. Survival Survival according to stage: Figures 3 and 4 show the 10-year survival of testicular patients according to clinical stage and histologic type. Patients with earlier clinical stage had better survival than those with late stage disease. The survival according to pathologic stage in Figures 5 and 6 are similar to those reported for clinical stage. TABLE 12. Histologic Condition Histologic condition Seminoma Nonseminoma Type of surgery No. Percent No. Percent Histology by Type of Surgery n 95.2% of the long-term study patients and 96.1% of the short-term study patients, orchiectomy only was the type of surgery used for seminoma (Table 12). Orchiectomy was done on 43.0% of the long-term and 43.6% of the short-term study nonseminoma patients, and orchiectomy with retroperitoneal node dissection was done on 55.9% of the long-term and 55.1% of the shortterm study nonseminoma patients. Fewer than 5% of the patients with seminoma in both studies received orchiectomy and retroperitoneal lymphadenectomy. Orchiectom y Orchiectomy + retroperitoneal 1538 node dissection 69 Biopsy only 0 Other 9 Total 1616 Orchiectomy Orchiectomy + retroperitoneal 926 node dissection 32 Biopsy only 0 Other 6 Total

8 1928 CANCER October Vol showed higher 1-year survival rates in all stages of disease, especially in Stage 1 and 111 disease (Table 15). While this was true for both the seminoma and nonseminoma patients, the improvement is greater among nonseminoma patients where the need for improved outcomes historically has been greater SEMNOMA - Clinical Stage 111 (11344) -- Clinical Stage (~162) - Clinical Stage (na658) Discussion The data for these studies were contributed by a large number of independent institutions that participated on a voluntary basis. The data were abstracted by trained tumor registrars and reviewed by the cancer committees of individual hospitals. The large number of contributors and the impracticality of detailed auditing of each contributor s accuracy may raise concerns about the possibilities of error and bias in reporting. Furthermore, instances of missing data or reporting of important patient, disease, or treatment variables as unknown may limit the precision of assessments of variations in patterns of care. These concerns notwithstanding, these data may provide reasonable descriptions of the management and survival of patients with testicular cancer in the US at two points in time. Some evidence of validity is the close 100 The pathologic stage system also shows that patients with advancing stage disease had poorer survival rates. t is emphasized that these 1 0-year survival figures represent survival of patients treated before December 3 1, Survival according to histologic type: The calculated ten-year survival rates ranged from 9 1.7% for seminoma patients to 44.2% for patients with choriocarcinoma. For embryonal carcinoma, the survival rate was 64.4% and for teratoma, it was 7 1.8% (Table 13). This includes all stages. Siirvival according to histologic type and pathologic stage: Patients with seminoma survived longer than patients with nonseminoma within each stage of the disease. Patients with seminoma and pathologic Stage reported a 5-year survival rate of 97.5% and a 10-year survival rate of 96.4% (Table 14). Nonseminoma patients with Stage 111 disease had a 5-year survival rate of 22.6% and a 10-year survival rate of 22.1%. The 10-year survival figures reflect the survival before the era of chemotherapy employing vinblastine, bleomycin, and cisplatin. versus long-term 1-year survival: Compared with the pre-1975 patients, patients diagnosed in > v) Lc 0 Y C $ 40 0) a 20 0 N ON-SEM NOMA - Clinical Stage 111 (nn176) -- Clinical Stage (n-152) - Clinical Stage (n-457) Months from Diagnosis FG. 4. Ten-year survival of patients with nonseminoma ofthe testis by clinical stage diagnosed before December 31, 1975.

9 No. 8 PATTERNS OF TESTS CANCER CARE - Kennedj. el al correspondence of the patient characteristics we have measured and the same characteristics assessed in the National Cancer nstitute SEER program. Furthermore, reauditing of a randomly selected series of patients in a previous study of breast cancer showed that the survey procedures yielded data which was 98% reproducible for a number of patients and treatment variable^.^ This shows that the procedures employed have been subjected to earlier quality assurance assessment. Another quality control measure is the practice of the data center of returning to the individual hospital registrars a computerized summary of their specific hospital reports. These summary statistics were to be reviewed before the Cancer Committee and instances of error reported to the data center for correction. We have limited the interpretation of diflerences and trends to such magnitude that they are unlikely to be the product of an error process. Where some responses are unknown, we have restricted comparison of rates and proportions to those rates and proportions to those patients for whom complete data were reported. Although these data provide a source of information and a perspective that is unobtainable from single institutions or clinical trials, the data are not suited for as- NON-SEMNOMA ---- Path. Stage 111 (n=195) -- Path. Stage (na318) - Path. Stage (n-551) Months from Diagnosis FG. 6. Ten-year survival ofpatients with nonseminoma of the testis by pathologic stage. # C 8 40{ L a, a,oi 0, SEMNOMA ---- Path. Stage 111 (n-55) -- Path. Stage 11 (n-112) - Path. Stage (n-792) sessment of the relative efficacy of different treatments. Appropriately, this is a topic for clinical research with controlled randomization. Comparison of the long- and short-term study data showed little change in the demographic characteristics of patients. Between the long- and short-term study, there has been no apparent change or improvement in who first detects the presence of the tumor. However, the increase of the incidence of the symptom of a lump in the testis from 23.1% to 3.2% might suggest an increased public awareness of this disease. There also was a substantial increase, from 44.5% to , in reporting of a mass in the testis as a sign of cancer. perhaps reflecting again the earlier detection of the disease by the patient or the physician. The changes in the modes of diagnoses mirror the changing technology of tumor diagnosis and a better understanding of this disease. CAT scans and the serum biologic markers (alphafetoprotein, human chorionic gonadotropin, lactate dehydrogenase) were used more frequently in patients diagnosed more recently. The concomitant increased incidence of positive tests may reflect an increased proficiency in employing these technologies. The use of the cumbersome urinary gonadotropin test largely was replaced by the serum test. The

10 ~~ 1930 CANCER October Vol. 60 TABLE Year Survival Rates of All Stages of Testicular Cancer Patients by Histologic Type Histologic type Seminoma Teratocarcinoma Embryonal carcinoma Choriocarcinoma Teratoma Embryonal + seminoma Embryonal + teratoma + seminoma Teratoma + seminoma Choriocarcinoma + other combination Seminoma + teratocarcinoma 10-year survival rates Percent No TABLE Year Survival Rates for Testicular Cancer Patients by Histologic Type and Pathologic Stage 10-vear survival rates Seminoma Nonseminoma Pathologic stage Percent No. Percent No decrease in uses of the intravenous pyelogram, liver scan, and lymphogram represents replacement of these tests by CAT. The lack of change in the use of brain or bone nuclide scans with their low yields may reflect that these tests are only of value in the symptomatic patient and not of value as a screening tool. The five- to seventime more frequent use in the recent data of the biologic markers after orchiectomy suggests the growing recognition of the value in the use of these tests. n nonseminoma patients, the use of surgery and lesser radiotherapy has increased. As the disease stage TABLE 15. -Year Survival of Testicular Cancer Patients According to Histologic Type and Pathologic Stage Seminoma Nonseminoma Pathologic. t *? stage (W) (%) (8) ("/.) Year ofdiagnosis: t Year of diagnosis: advances, the use of surgery plus chemotherapy has increased, and radiotherapy use has decreased. This may reflect an increase in the use of adjuvant chemotherapy in Stage 1 as well as the use of chemotherapy when the disease was found to be more advanced. The 10-year survival rates demonstrate the excellent survival of patients with early disease; even in the nonseminoma tumors. n seminomas, more than 96% of patients with Stage disease survive 10 years. n Stage 11, the results are 84%. n the future, greater emphasis perhaps should be placed on determining why any deaths occur among these patients. Among the nonseminoma patients, the survival at 10 years decreases with advancing stage. For Stage 111 survival of 22.1 % reflects the pattern which predominated before the widespread use of chemotherapy. This figure should be expected to increase significantly as study of the post 1983 patients continues. At 1 year, the survival of Stage 111 patients was 78.4% for the post-1983 patients compared with 50.5% for the pre-1975 patients, a highly significant improvement (P < 0.00 l), clearly demonstrating the important advances in chemotherapy. Overall, this study of the pattern of care in cancer of the testis shows the impact of new technologies, better evaluation of the extent of disease, and the changes in therapy. All of those changes were achieved recently through clinical research. Comparison of 1 -year survival results between the 1975 and 1983 reference points suggest changes in success in treating testis cancer are significant and will increase as patients continue to be followed. Considered in aggregate, survey data suggest that cancer of the testis is a disease that may be cured in most patients with the combined application of early detection and the appropriate use of modern treatment modalities. REFERENCES 1. Natarajan N, Mettlin C, Murphy GP. Patterns-of-care surveys of the American College of Surgeons' Commission on Cancer. n: Mettlin C, Murphy GP, eds. Progress in Cancer Control 111: A Regional Approach. New York: Alan R. Liss, 1983; Kaplan EL, Meier P. Non-parametric estimations from incomplete observations. JAm Slat Assoc 1958; 53: Young JL Jr, Percy CL, Asire AJ. Surveillance, epidemiology and end results: ncidence and mortality data, Washington, DC: National Cancer nstitute Monograph 57. DHEW publication no. (NH) , Sondik EJ, Young JL, Horn JW, Ries LAG Annual Cancer Statistics Review. Bethesda, Maryland: National nstitutes of Health NO , 1987;.B.25,.B Wilson RE, Donegan WL. Mettlin C, Natarajan N. Smart CR, Murphy GP. The 1982 national survey of carcinoma of the breast in the United States by the American College of Surgeons. Sztrg Gynecol Obstet 1984; 159:309.