1xBEP vs 2xBEP

[Zicarias]

Hi everyone I've been diagnosed with clinical stage 1B with primary embryonal carcinoma and LVI and am considering adjuvant chemotherapy. My oncologist is recommending 2xBEP but Dr. Einhorn is recommending 1xBEP and actually advised against 2xBEP. Does anyone have any opinions or information for one or the other?

Is the thinking that 1 round leaves open the option of 3xBEP is reoccurance happens? What about chemo resistance?

Edit: I have two more blood tests scheduled to make sure my AFP returns to normal; if not I have to do 3xBEP.

Thanks in advance!

[Nish115]

Recent studies have shown 1xBEP to have pretty much identical success rates as 2xBEP in terms of adjuvant chemo hence why Dr E is recommending 1xBEP. Some oncologists depending on location still recommend 2xBEP as they are more conservative and haven't undertaken studies themselves so don't rely on them. If Dr. E recommends 1xBEP then that's what i'd go with.

[RJKD]

Well, a recent UK study was done. From what I remember, it was over 100 patients that did 1 x BEP. Only 1.3% needed further chemotherapy. A further 1.3% needed RPLND. So the total relapse rate after 1 x BEP was 2.6%. 2 x BEP will not improve this. The best TC oncologist (Dr E) recommends that.

I never even considered 2 x BEP. It's easy for a doctor to throw chemo at their patients. But doctors rarely ever put themselves in the position of their patients. I know because I see it all the time in the medical field.

[Zicarias]

That makes complete sense and I definitely trust Dr. Einhorn's opinion. My oncologist is comfortable with either but recommends 2xBEP. He said that it's possible over the next few years as more studies are done many doctors may decide that one is sufficient.

[Davepet]

Doc E is the one who I would trust with this. He's likely treated hundreds more cases than your doc (maybe thousands). He knows how to beat this.

Dave

[RJKD]

That makes complete sense and I definitely trust Dr. Einhorn's opinion. My oncologist is comfortable with either but recommends 2xBEP. He said that it's possible over the next few years as more studies are done many doctors may decide that one is sufficient.

Well, your doc is wrong. Those studies have already been done. We have at least 3 well done, relatively large studies that show that 1 x BEP is about 97-99% effective. There are many smaller studies as well. I'm not sure what further studies your doc needs. It's overwhelmingly likely that if he gives you 2 x BEP, he will be overtreating you. Einhorn is a logical man and on top of the research and that's why I would only listen to him.

RPLND and surveillance are also completely viable options here too.

[Zicarias]

Thanks guys, if I choose chemo I would do 1xBEP for sure. After emailing Dr. E and reading those studies I wouldn't do 2. I saw a new urologist today and after reviewing my images he saw a 7mm node on my pre-op CT scan. He said its under 10 so considered negative but now I'm seriously considering RPLND again. I have another CT scan scheduled for Tuesday and have to make a choice by Wednesday to get either option scheduled in time. Also all my blood markers have returned to normal which is good.

[RJKD]

Do you have pure EC? I'm curious to know the percentage of EC you have. RPLND is a completely viable option. Just make sure it's an open procedure, and I would recommend bilateral. It is not nearly as effective as 1 x BEP, but it still has therapeutic benefit.

[Zicarias]

I have 70% EC. If I go the RPLND route I would do open bilateral. The surgeon mentioned the outcome for relapse after RPLND goes down significantly, around 50% mortality. Is this for late relapses or any relapse because I always thought 3xBEP was effective for a post RPLND relapse

[RJKD]

Mortality does not change with either 1 x BEP, RPLND, or surveillance routes. Relapse does change. In general, there's a 50% reduction in relapse after an RPLND. So if you're at a 50% relapse rate right now, then overall it reduces to about 25% or so. However, these are very general numbers. I prefer to think about it in terms of whether something is found in your lymph nodes.
If all your lymph nodes are empty, the relapse rate becomes about 10%
If you are pN1 (1-5 lymph nodes affected) then the relapse rate becomes approx 20-30%.
If you are pN2, it is recommended you proceed with 2 x BEP afterwards as the relapse rate is so high.

The chance of finding anything in your lymph nodes at this time is approx 25%.

[Zicarias]

Interesting. That's a good way to look at it, thank you. Is it unheard of to do 1xBEP or 2xBEP if you are pN1 after RPLND?

[RJKD]

Interesting. That's a good way to look at it, thank you. Is it unheard of to do 1xBEP or 2xBEP if you are pN1 after RPLND?

It's not uncommon at all to do 2 x BEP for pN1 disease. 1 x BEP would not be recommended and no oncologist will recommend it. We simply don't have studies on it. I suspect actually it would likely be effective, but I would need a study on it before I would recommend it.

[Zicarias]

That's what's the most concerning to me, the urologist I saw last week for a second opinion showed me a 7mm node on my pre-op CT scan. That's awfully close to the 10mm limit to be considered node positive, which would upgrade me from 1B to 2A and rule out 1xBEP. Which is why I'm nervous about doing 1xBEP now. I have a post-op CT scan Tuesday which I'm hoping makes this decision easier.

I suppose I could always do RPLND and take the unknown out of the equation.

[Zicarias]

Small update: I started on 1xBEP today. Post op scan of chest and abdomen showed no enlarged nodes so doctors are confident in 1B staging.