Alternatives to 3xBEP in Good Prognosis GCT-You Bet Your Life-Editorial

[Paul54]

Many of us continue participating in the forum for, among other reasons, the hope of being able to rejoice at the discovery of breakthoughs in diagnosis and treatment that would reduce suffering and save lives. Most of the time, though, we are thankful that treatments exist that help keep the survival rate to 95%. The below link is to an editorial, which I think is accessible without any sort of login by a friend of the TC community, Dr. Craig Nichols, that confirms that 3xBEP is state-of-the-art. While I hope I don't have to endure any chemo, there is some satisfaction that it is there if I need it. Note references to work by Drs. Einhorn, Jewett, and Horwich, including some recent papers.

http://jnci.oxfordjournals.org/cgi/reprint/djq266v1

[Smartie]

Paul - thank you very much for finding and posting this. I believe the article has big implications for the forum. Specifically, we always tell people that 3xBEP and 4xEP are equally effective, but Dr Nichols disagrees:

[...]in terms of routine clinical practice, there must be a compelling
medical reason to use etoposide and cisplatin for four cycles rather than BEP × 3 (eg, advanced age, substantial renal insufficiency,
demonstrable clinically significant pulmonary compromise), and these two regimens should not be viewed as equally effective options. (italics mine)

Also, we often -quite rightly - tell people that delays in chemo treatment are associated with poorer outcomes. Until now, the only source I could find for this was the interview (about ten years old) with Dr Nichols on the TCRC. Now we can also point to this far more recent and officially published article, and to these words:

There is now sufficient evidence to say that deviation from standard BEP × 3 is a potentially life-threatening decision and, therefore, requires a corresponding life-threatening reason to drop bleomycin or to extend the 21-day schedule or to tinker with the etoposide dose. (italics mine)

All in all, a remarkable publication with far-reaching ramifications for TC patients who are considering their options.

[TCdoc]

Actually if you look at reference 7 the french authors state that there is no significant difference between x3 BEP and x4 EP.

[Davepet]

Originally Posted by TCdoc

Actually if you look at reference 7 the french authors state that there is no significant difference between x3 BEP and x4 EP.

Where did you see that, TCdoc? All I saw was:

This question has been addressed formally by a random-
ized trial conducted in France (7), in which it was concluded that
standard BEP × 3 was the superior regimen and that further inves-
tigation of this issue was not warranted; standard BEP × 3 has thus
become the recommended therapy for good-prognosis dissemi-
nated germ cell tumors throughout Europe and in Canada.

Which seems to say the opposite...
Could you provide a link to further info?
Dave

[TCdoc]

The authors of ref 7 say in their results

"Among 257 assessable patients, 124 and 122 patients achieved a favorable response in the 3BEP and 4EP arms, respectively (P = 0.34). Median follow-up was 53 months. The 4-year event-free survival rates were 91% and 86%, respectively (P = 0.135). The 4-year overall survival rates were not significantly different [five deaths versus 12 deaths, respectively (P = 0.096)]. Similar nonsignificant trends were observed in good IGCCCG prognosis patients."

They do say, however, that BEP should be first line therapy which it is.

http://annonc.oxfordjournals.org/con...e2=tf_ipsecsha

[Davepet]

Originally Posted by TCdoc

[five deaths versus 12 deaths, respectively (P = 0.096)]. Similar nonsignificant trends were observed in good IGCCCG prognosis patients."
http://annonc.oxfordjournals.org/con...e2=tf_ipsecsha

I realize I'm not really up on statistics, but it seems to me that over twice as many deaths in similar sized groups should be significant. While there *is* potential for lung damage with bleo, it is also not all that common, I'm told. I guess it's all about which gamble you feel more comfortable with...

Dave

[Paul54]

Dr. Nichols experience and opinions aside, some centers of excellence like Memorial Sloan Kettering in New York clearly prefer 4xEP, primarily due to the lung toxicity of the Bleo. Large studies show that 3xBEP and 4xEP are equally effective over the long term.