June 7, 2010
To help doctors give their patients the best possible care, the American Society of Clinical Oncology (ASCO) asks its medical experts to develop evidence-based recommendations for testing blood levels of tumor markers for germ cell tumors. The tumor markers recommended in this guide are based on the results of clinical trials of patients with germ cell tumors.
Watch a patient education video led by Dr. Timothy Gilligan explaining this ASCO guideline on tumor markers for this specific type of tumor.
- Certain tumor markers may be found in the blood of men with germ cell tumors, most commonly testicular cancer.
- Doctors may test levels of these tumor markers before, during, and after treatment to monitor the cancer or check if it has returned.
- Talk with your doctor about when these tumor markers will be measured and how the results are used to monitor treatment and recovery.
A germ cell tumor is a cancer that develops from cells in the reproductive system called germ cells. In men, germ cells are responsible for producing sperm. Most germ cell tumors in teenage boys and men start in one of the testicles. There are two different categories of germ cell tumors: seminoma and non-seminoma. Generally, seminomas grow and spread more slowly than non-seminomas, but both types of tumors should be treated quickly.
A germ cell tumor can also develop in other parts of the body, such as the retroperitoneum (the back of the abdomen near the spine), the mediastinum (the central portion of the chest between the lungs), the lower spine, and very rarely, the pineal gland (a small gland in the brain).
During diagnosis of a germ cell tumor, a sample of blood may be collected to test for levels of serum tumor markers, which are substances produced by a cancer that are found at abnormally high levels in the blood of a person with that cancer. High levels of any one of three tumor markers, called alpha-fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH), may indicate a germ cell tumor. High AFP levels can also help identify the type of germ cell tumor, by showing whether it is a pure seminoma or mixed with non-seminoma, since AFP is not made by seminomas. However, hCG and/or LDH can be higher if a man has a seminoma, non-seminoma, or mixed tumor. If markers are elevated at diagnosis, changes in their levels can tell your doctor whether the tumor is responding to treatment.
To help doctors determine when to use AFP, hCG, and LDH test results to monitor treatment and follow-up care, ASCO recommends the following:
- AFP and hCG should not be used to screen for germ cell tumors, to decide whether orchiectomy (surgery to remove one or both testicles) is needed, or to make treatment decisions for patients with cancer of unknown primary, which means that the site where the cancer began cannot be identified.
- For all patients undergoing removal of a testicle (orchiectomy) for suspected testicular cancer, AFP, hCG and LDH should be measured. If levels are high before orchiectomy, they should be checked after orchiectomy to find out if they are returning to normal.
- To determine the stage and prognosis (chance of recovery) of a non-seminoma, AFP and hCG should be measured before orchiectomy. Also, AFP, hCG, and LDH should be measured after orchiectomy and before other treatment begins for testicular cancer, and before chemotherapy for patients with non-seminoma that began outside of the testicles.
- AFP and hCG should be measured before retroperitoneal lymph node dissection (RPLND; removal of the lymph nodes in the back of the abdomen), before each cycle of chemotherapy begins for non-seminoma, after all chemotherapy is finished, and periodically after treatment ends to watch for a recurrence (return of cancer after treatment). Read below to learn when these tests are recommended.
- For patients with testicular pure seminoma that has spread to other parts of the body (stage II or III disease) and for seminomas that began somewhere other than the testicle, hCG and AFP should be measured periodically after treatment ends to help monitor for a return of the cancer. Read below to learn when these tests are recommended.
- Tumor markers should not be used to make or change treatment decisions for seminoma, or to watch for a recurrence of stage I seminoma.
What This Means for Patients
Patients diagnosed with a germ cell tumor may need special blood tests to test for tumor markers at different times before, during, and after treatment in addition to standard imaging tests. Talk with your doctor about what tests are needed for your type and stage of cancer, what the test results mean, and how often you'll need to be tested. For men with non-seminoma and advanced seminoma, it's important to continue with follow-up testing of tumor marker levels after treatment for a germ cell tumor ends, particularly because increases in the tumor markers levels are often the first sign that the cancer has returned. ASCO recommends the following schedule for testing tumor marker levels:
- For non-seminoma, AFP and hCG should be measured every one to two months in the first year after treatment ends, every two to four months in the second year, every three to six months in the third and fourth years, every six months in the fifth year, and annually thereafter, continuing for at least 10 years.
- For advanced seminoma, tumor marker levels should be tested every two to four months in the first year after treatment ends, every three to four months in the second year, every four to six months in the third and fourth years, and annually thereafter, continuing for at least 10 years.
In addition to testing tumor marker levels, additional tests, such as computed tomography (CT) scans, magnetic resonance imaging (MRI), and lung function, may be needed as part of your follow-up care for a germ cell tumor. Talk with your doctor about these tests and when they should be done because the schedule will likely be different from the tumor marker testing schedules listed above.
Questions to Ask the Doctor
To learn more about serum tumor marker testing for a germ cell tumor such as testicular cancer, consider asking your doctor the following questions:
- What type of germ cell tumor do I have? Is it testicular cancer, or another type? Is it seminoma, non-seminoma, or a mixed germ cell tumor?
- Can I obtain a copy of my pathology report (laboratory test results and tissue diagnosis)?
- What blood tests will I need to have to look at serum tumor marker levels? When should these tests be done?
- Based on these test results, what treatments do you recommend and why?
- What are the possible side effects of these treatments?
- After treatment ends, what is my schedule for serum tumor marker measurements and other evaluations during follow-up care?
- Who will be monitoring my follow-up care; my oncologist or primary care doctor?
- Who should I talk with if I have questions about health insurance and the cost of follow-up care?
The information in this guide is not intended as medical or legal advice, or as a substitute for consultation with a physician or other licensed health care provider. Patients with health care-related questions should call or see their physician or other health care provider promptly, and should not disregard professional medical advice, or delay seeking it, because of information encountered in this guide. The mention of any product, service, or treatment in this guide should not be construed as an ASCO endorsement. ASCO is not responsible for any injury or damage to persons or property arising out of or related to any use of this patient guide, or to any errors or omissions.
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