COST AND RISK-BENEFIT IN THE MANAGEMENT OF CLINICAL STAGE-II NONSEMINOMATOUS TESTICULAR-TUMORS

Background. Two similarly effective treatment options exist for managi ng clinical low volume Stage II nonseminomatous germ cell testis tumor s (NSGCT). Primary retroperitoneal lymph node dissection (RPLND) (with immediate adjuvant chemotherapy or chemotherapy at relapse) and prima ry chemotherapy have resulted in similar survival rates in large serie s. Because the chance for cure is similar with either approach, the co st and morbidity of therapy should be considered important discriminat ing factors in deciding which option to pursue for an individual patie nt. The purpose of this study was to undertake a cost/benefit and risk /benefit analysis of these two options using data and costs from the I ndiana University experience. Methods. The overall direct costs for 10 0 patients undergoing primary RPLND were compared with the total direc t costs of 100 patients receiving primary chemotherapy for low volume Stage II disease, including the costs of adjuvant chemotherapy, salvag e chemotherapy in relapsing patients, and routine follow-up for a 5-ye ar period. In addition, the two treatment options were analyzed relati ve to survival, late relapse, acute and chronic toxicity, (including f ertility), and perioperative morbidity. Results. In this analysis, the overall 5-year costs of RPLND were significantly less than the costs of primary chemotherapy. The two options did not differ significantly in terms of survival or quality of life. Patients receiving RPLND were found to have an advantage also in terms of fertility, toxicity, and late relapse. Conclusions. Treatment decisions for patients with clini cal low volume Stage II NSGCT may be based on cost/benefit and risk/be nefit considerations, including relative toxicity, long term cure rate , and individual patient preference. Patient compliance with follow-up , the specific expertise of the physicians, and the availability of sp ecialized therapeutic care ultimately may influence such decisions.