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One cycle vs. three cycles of BEP for high risk stage 1 NSCGT

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  • One cycle vs. three cycles of BEP for high risk stage 1 NSCGT

    New to the community, here's my quick rundown:
    10/4: noticed lump in R testicle
    10/11: ultrasound confirmed mass.
    labs showed slightly elevated (<1.5) LDH, slightly elevated beta-HCG (17), normal AFP (2.1). CT scan clear, other than testis.
    10/16: unilateral orchiectomy
    10/25: biopsy result: non seminoma 100% embryonal. LVI +, but tumor confined to testis.
    lab showed elevated beta-HCG (24)...apparently urologist didn't order labs for other markers?

    I guess a little more background might be useful: my brother had testicular cancer in 2016, the exact same cancer (pure embryonal NSGCT), though his presented at stage 2, already in the lungs. He did bep x3 after the orchiectomy, and has been clear since then. When I was first diagnosed I sent my results to him and he forwarded them to his doctor (Dr. Tu at MD Anderson), who recommended bep x1 as adjuvant treatment to decrease chance of relapse from 60% to 3%.

    The oncologist I was referred to by my urologist recommended surveillance, and if I relapse would recommend bep x3. However, when I mentioned the idea of a single round of bep the doctor had never heard of it, which makes me think he's probably not an expert in TC (also, he basically just read the NCCN guidelines to give me my staging, which I had already done myself). I'm in the process of setting up an appointment with Dr. Tu, even though that it involves a flight to Houston. But here's my question, finally:

    Is there a significant difference between the toxicities and morbidity associated with only ONE cycle vs. three cycles of BEP? I obviously don't want to overtreat and go through chemo unnecessarily, so surveillance sounds nice. But I'm also in the high-risk group of stage 1 NSCGT since I have high content embryonal AND lymphovascular invasion. So if I could do one cycle now instead of three cycles later, what exactly would I be saving myself from? I've had a hard time finding any studies discussing whether fewer cycles (lower cumulative dose) of bep is associated with a decrease in the potential long-term effects of chemo.

    Any resources or personal experience would be much appreciated, thanks.

  • #2
    Sorry, changed my search terms and finally found that someone had already started this conversation elsewhere on the forum. Discussion can be found here:
    Last edited by tdub; 10-31-18, 03:38 PM.


    • #3
      With your staging it’s 50% risk of relapse.

      There is not enough data to adequately compare long term outcomes of 1xBEP vs 3xBEP.

      It seems logical that the effect should be less but by how much? So far I have not gotten an answer on that.

      Don’t forget about RPLND. It’s also an option that reduced the risk to about 20% IIRC.

      Send me a PM and I can send you my lot of research papers on stage 1 EC.
      Age 31 - Portland, OR
      01NOV16- Pain in right testicle, palpable mass
      13NOV16- R I/O. Markers normal
      27NOV16- Stage Ia non-seminoma, 1.3cm, 100% EC, no LVI
      06DEC16 - CT scan clear
      09DEC16 - Started 1xBEP. Neutropenic at day 15; Worst part for me was bleo (allergic).
      03JAN17- Ended 1xBEP; start surveillance
      18MAR17-2nd pathology report shows 90% EC , 10% seminoma


      • #4
        I did 1xBEP, and even though the treatment was three weeks from hell, I recovered pretty quickly. The side effects I experienced were bone/joint pain from the Nuelasta and extreme fatigue, plus of course the hair loss. There were some days when I could barely get out of bed, but once the treatment was over, it took me a couple of weeks to get back to working out.

        I should mention that I am young (30; had the treatment when I was 29) and fit.

        I am about 7 months out of treatment, and the only long-term side effect I have experienced so far is that my hair has been falling in some places and growing slower in others, months after it came back.


        • #5
          Originally posted by tdub View Post
          So if I could do one cycle now instead of three cycles later, what exactly would I be saving myself from?
          Afraid nobody actually knows, they have only been successfully treating TC for about 40 years now, while that might seem like a long time, it is not long enough to answer your question. Personally, I would take the 50% chance I was already cured & know that if I lose, I get 3xBEP. At that point, there is no doubt I need the poison.

          Taking a smaller dose of the poison in the hopes I reduce the need for a larger dose is *way* less attractive to me, other guys prefer that option. We are at least 30-50 years away from finding out which approach is best, so for now, your personal risk tolerance is all you have to work with. Sorry, I can't help more.
          Jan, 1975: Right I/O, followed by RPLND
          Dec, 2009: Left I/O, followed by 3xBEP


          • #6
            Don't forget RPLND. It is an option here.
            Diagnosed at age 31. Treated in NYC. Now living in Ottawa, ON, Canada.

            7/1/2015: felt tiny lump on side of R testicle
            7/30/2015: Ultrasound shows 2 intra-testicular masses.
            7/31/2015: tumor markers normal, CXR clear
            8/5/2015: R orchiectomy
            8/11/2015: Pathology: 1.2 x 1.0 x 1.0 cm, embryonal 80%, seminoma 20%, with LVI and rete testis invasion
            8/14/2015: CT abdomen/pelvis clear, Stage 1b
            8/24/2015: started 1 x BEP


            • #7
              This is obviously a tough decision and one that has to be right for YOU as there is no necessarily right or wrong decision as the survival rate is basically 100% with any choice.

              There have been two more recent publications/editorials that I think are useful and you may as well as far as a review of the options:

              I would consider 3 more personal parts of the decision:

              1. Am I the type of person (personality type) that needs to do everything I can now to reduce my risk of relapse? For example, will I be upset with myself if I relapse because I didn't do something up front or will the increase risk cause me great anxiety during my check ups.

              2. How can I handle my follow up? Will I be compliant on surveillance and have insurance and access to care? Can I meet the demands of the more rigorous follow up or would less intense follow up after initial adjuvant chemo or RPLND be better?

              3. How will a relapse affect my life? If I relapse a year or two from now can I pause life to receive treatments or would that pause be catastrophic compared to doing something now to reduce the risk?

              It is certainly a bit more complicated than these 3 things but I think it comes down to the individuals fears (fear of chemo, surgery, relapse) and their risk tolerance.

              Oct. 2005 felt lump but waited over 7 months.
              06.15.06 "You have Cancer"
              06.26.06 Left I/O
              06.29.06 Personal Cancer Diagnosis Date: Got my own pathology report from medical records.
              06.30.06 It's Official - Stage I Seminoma
              Founded the Testicular Cancer Society
              6.29.13 Summited Mt. Kilimanjaro for 7th Cancerversary

              For some reason I do not get notices of private messages on here so please feel free to email me directly at if you would like to chat privately so as to avoid any delays.


              • #8
                First,so sorry for you diagnosis. But, grateful that you do testicular checks given your family history! I know you plan to see Dr. Tu at MD Anderson, but maybe also email Dr. Lawrence Einhorn before traveling. I see that many have mentioned RPLND and that is a viable choice in your case. Too many are afraid of the surgery, for my son chemo had a longer recovery time than RPNLD. Mike laid out the big questions to ask if you choose to not confer via email with Dr.Einhorn.
                Son Grant
                dx 12/21/16 at age 17

                BEP x3
                Post Chemo CT Scan on 3/28/17 still showed a few nodes over 2 cm
                2nd Post Chemo CT Scan on 4/27/17 showed all nodes still over 2cm
                Post Chemo RPLND 5/8/17: Periaortic Teratoma, Intraaorticaval Teratoma, and Paracaval Teratoma found.


                • #9
                  Thanks for the responses, y'all. And @Trekga I did email Dr. Einhorn, which was helpful. But unfortunately I no longer have much choice--tumor markers in the weeks after the I/O continued to rise, so everyone (doctor in Houston, Einhorn, doctor here in Memphis) is recommending BEP x3. So I'm starting treatment in a couple weeks.


                  • #10
                    I am sorry hearing your tumor markers elevated. But I think your brother had been cured by BEPx3. That will be a little bit helpful to get some information before chemo. Everyone is reacting differently to BEP. My son finished long week last week and today he will get Bleomycin shot. In general he managed side effects not bad, everyday he drinks more than 3,000ml water, and he slept a lot. Today he feels like normal. We are expecting more side effects coming out next cycle, but we will be happy then we are more close to the end of treatments.

                    I wish your chemo treatments going well as possible as you can.

                    Amy, Ryan’s mum
                    Son Ran, 24 years old, 25th May 2018 diagnosed NSGCT. 28th May 2018 right orchiectomy. Pathology:50% EC, 30% Teratoma,20% Yolk sac. CTs: 1 retroperitoneal lymph node 0.7mm Tumor markers: AFP 497, bhcg 19, LDH normal Normalized after R/O. Stage 1, surveillance 17th September 2018, Bhcg elevated up to 5.6 AFP and LDH normal, CT stable. 4th November bhcg up to 28, AFP and LDH normal. BEPx3 started and 2nd January 2019 BEP finished with Tumor markers normalized. 13th February 2019 CT scan showed 1 retroperitoneal lymph node enlarged up to 1.1 cm with normal tumor markers. RPLND : 03/14 2019@IU Dr.Cary Pathology report: one lymph node from 57 is Teretoma .Back to surveillance 05/02/19 Blood work all normal