Chemotherapy programs in advanced disease

Germ cell tumors (GCT) are considered a model for curable cancer based on the successful treatment of metastatic disease with cisplatin-containing chemotherapy (More than 90% of newly diagnosed GCT patients are cured.) [1]. Accumulated data from phase II and III trials show that treatment with cisplatin, vinblastine, and bleomycin (VAB series, PVB) achieves a durable response in 70% to 80% of patients who have metastatic GCT [2-5]. Treatment-related toxicity was substantial in these regimens, however, including hematologic, gastrointestinal, neurologic, dermatologic, and pulmonary toxicities [3].

In an effort to decrease toxicity while maintaining a high rate of cure, patients are stratified into ''good-risk'' and ''poor-risk'' groups by using

* Corresponding author. Genitourinary Oncology Service, Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10021.

E-mail address: [email protected] (G.V. Kondagunta).

prognostic criteria based on primary site, extent of disease, and serum tumor markers. The goal with good-risk patients is to maintain the high cure rate but minimize the toxicity of the treatment regimen. Standard good-risk regimens (three cycles of cisplatin, etoposide, and bleomycin [BEP]; and four cycles of etoposide and cisplatin [EP]) were established in randomized trials [6-10]. These regimens were shown to result in a durable complete response in approximately 90% of good-risk patients. The high cure rate achieved in patients who had metastatic disease led to the use of good-risk regimens in the postoperative (adjuvant) setting, following RPLND as primary treatment. In contrast, only half of all patients who had poor-risk features achieved a durable complete response to four cycles of BEP [3,11]. The goal in this poor-risk population is to increase the cure rate, with reduction of toxicity as a secondary objective.

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