ASCO 2012, Chicago, USA

Retrospective study of optimal treatment for intermediate-risk testes cancer

 Dr Constantine Albany – Indiana University, Indianapolis, USA

Dr Albany, Constantine Albany, you’re hot from the session, you’ve been talking about testicular cancer. The big issue here is knowing how much you can reduce the therapy or fine tune it, isn’t it? Is that what your study was all about?

This was a retrospective study. We looked at Indiana University experience over the last ten years and, as you know, testes cancer is a highly curable disease. A lot of studies have been done but still we’re trying to find the best tuning of treatment of those patients.

What did you do in the study that you’ve just been quoting?

We looked a sub-group of patients, of testes cancer, who are classified as intermediate risk; there is a classification that classifies patients into good, intermediate and poor risk. We clearly know to treat the good risk and the poor risk, however, the treatment of the intermediate risk is not very well defined.

And intermediate risk is still not a particularly big risk, is it?

It’s in-between and the survival rate in general, from a historical database, is about 70%. However, we looked at our patient population over the last ten years and our survival rate is actually in the 90%.

Which doesn’t make your job any easier because you’re trying to fine-tune this.

Right. So what happened, we treated patients with the standard of care, which is four cycles of chemotherapy called BEP. But also some patients, we treated them with less aggressive chemotherapy, which is three cycles and eliminating the bleomycin from the last cycle of chemotherapy.

What happened?

We saw actually the same outcome. So patients still had a very high curable disease with less aggressive chemotherapy.

It’s a  nice problem to have, they do well whatever you do.

Absolutely, less toxicity from chemotherapy. So we reduced the chemo without putting those patients at higher risk of relapse.

What has come out of this then in terms of an actual list of what you should do, then, for these patients?

Let me give you some data. We had 84 patients, consecutive patients, treated at IU. Almost half of them treated with this four cycles of BEP and the other half with BEP times three plus EP. As I said, the survival rate is about 90% over two years. Now, the tumour markers that tell us that this is intermediate risk were similar in both groups but we realise that this is a retrospective analysis, it’s not prospective, it’s not randomised double blind. We’re not claiming here that we should treat all patients with intermediate-risk testes cancer with this regimen that we treated them with. What we’re saying is that this group is really a very heterogeneous group; some of them, indeed, they need to be treated with four cycles because they’re very close to the poor risk category. But a lot of them, they are closer to the good risk category and they probably should not be treated with aggressive chemo but less aggressive chemo.

So what are the conclusions coming out of your study?

We’re concluding that the optimal treatment for intermediate risk is not well defined and that we probably should get international collaboration to better clarification or stratification for the intermediate risk group to better understand how to treat those patients.

Now busy cancer doctors have to make decisions, what’s your advice to them provisionally at the moment then?

Use clinical judgement. Just an example that makes a lot of sense: if you treat two patients with intermediate risk, one of them has two primary metastases and beta HCG of 6,000; another patient has 40,000 of beta HCG and hundreds of primary mets. They’re actually both under the umbrella of intermediate risk disease, however, they are so different in their outcome. So the first patient we treat, if I was treating him, with less aggressive chemo, however, the second patient is more aggressive disease, we treat him with four cycles of BEP.

And how optimistic are you that this situation will clarify in the future? Are there things like markers?

Absolutely, we’re actually having a meeting today with Dr Reiner on a multiple international collaboration from all over the world to have a further talk about this and how to go from here.

And other modalities of chemotherapy maybe?

No, actually it’s difficult to run a randomised study, it’s a rare subset of patients and it really takes ten years to identify only 84 patients. We don’t think we’ll be able to run a randomised study, however, just better classification of those patients to know how to better understand them and better how to treat them.

So the bottom line take home message today for doctors, in just a few words, would be what?

Intermediate-risk testes cancer is a heterogeneous group. Not all patients should be treated the same. I think that’s the message.

Thank you very much.

You’re welcome, thank you.