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GU Cancers 2019 | Readdressing the rationale of irradiation in Stage I seminoma guidelines

Gert De Meerleer, MD, PhD, of the Ghent University Hospital, Ghent, Belgium, speaks at the 2019 Genitourinary Cancers Symposium, held in San Francisco, CA. He gives his opinion on the rationale for irradiation in stage I of the seminoma guidelines.

Transcript (edited for clarity)

Well, at first for most Stage I seminoma, you can perform active surveillance and just follow the patient on a very strict base. But if you go for treatment then there has been this historically decision-making, certainly in Europe, that feel radiotherapy should not be offered anymore because according to those colleagues, it induces much more secondary tumors than chemotherapy...

Well, at first for most Stage I seminoma, you can perform active surveillance and just follow the patient on a very strict base. But if you go for treatment then there has been this historically decision-making, certainly in Europe, that feel radiotherapy should not be offered anymore because according to those colleagues, it induces much more secondary tumors than chemotherapy.

However, the radiotherapy schedules and the technology that they used to make the statement are very old, and should not be extrapolated in the current setting. With modern radiotherapy, for instance, with what you call arc therapy and certainly with proton therapy, which is coming up, the incidence of secondary tumors will be far less than it is with historically schedules. Number two, when you look at the statistics of this famous paper that was published in GCO, it’s a non-inferior trial which is not the same as ECO.

Non-inferior has stood something totally different and from a purely statistical viewpoint, it was not non-inferior. So, I think that radiation oncology has been kicked out far too early and that if a patient needs treatment for Stage I seminoma, it should be explained in two different ways: being carboplatin or being modern radiotherapy, also to a far lower dose because now we know that a dose of 20 Gy (gray) is sufficient to treat these patients, while all comparisons were made to schedules of 30 Gy (gray) and more. The higher the dose you give, the more chance of you also developing secondary tumors, so, that’s also an extra point in favor of radiotherapy – that you can give far lower doses than historically.

Secondly, or thirdly, the follow-up of those studies with carboplatin are very limited. So, the real results are the long-term we don’t know yet. I’m not saying that you cannot go for carboplatin, it’s fair to do so but, you cannot kick out radiation oncology because of historical data. This is scientifically not fair, and therefore we published this paper with the whole group of American and European radiation oncologists and urologists who are into the research of urologic tumors to inform the community, I think this is the main message.

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