Patients can experience a recurrence of cancer after initial therapy and/or become refractory to chemotherapy following treatment. Outcomes for patients with recurrent cancer depend on the extent of disease, prior therapy and the interval from primary treatment to relapse. Many patients with recurrent disease remain curable.
A variety of factors ultimately influence a patient’s decision to receive treatment of cancer. The purpose of receiving cancer treatment may be to improve symptoms through local control of the cancer, increase a patient’s chance of cure, or prolong a patient’s survival. The potential benefits of receiving cancer treatment must be carefully balanced with the potential risks of receiving cancer treatment.
The following is a general overview of the treatment of recurrent and/or refractory testicular non-seminoma. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied. The information on this Web site is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician.
Most new treatments are developed in clinical trials. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Clinical trials are available for most stages of cancer. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. To ensure that you are receiving the optimal treatment of your cancer, it is important to stay informed and follow the cancer news in order to learn about new treatments and the results of clinical trials.
Patients with Cancer Recurrence after Surgery or Radiation Therapy
Patients who experience a cancer recurrence after treatment with orchiectomy and/or radiation therapy can typically be treated with chemotherapy. The most frequently administered chemotherapy combinations include bleomycin, etoposide and Platinol® (BEP) for 3 courses or etoposide and Platinol® (EP) for 4 courses in good-prognosis patients. Over 90% of patients who relapse after surgery and/or radiation therapy appear cured with Platinol® based chemotherapy.
Treatment of Patients who Fail Initial Chemotherapy
Patients whose cancer progresses following Platinol®-based chemotherapy require treatment with different chemotherapy regimens. Currently available chemotherapy regimens can induce long-term complete remissions in approximately 25% of patients with cancer that persisted or recurred following initial Platinol®-based treatment. Patients who experience a complete response to initial chemotherapy and those without extensive disease at the time of recurrence have the most favorable outcomes.
Patients who are refractory to Platinol®-based chemotherapy have a markedly poor prognosis. Several chemotherapeutic agents have been evaluated in intensively treated or Platinol®-refractory patients. Doxorubin, Ellence®, Navelbine®, Hycamtin®, or biologic agents such as a suramin and retinoic acid have not demonstrated significant activity in Platinol®-refractory patients. However, paclitaxel has shown a response rate of approximately 21%, with a few patients having a complete response. Current clinical trials are evaluating paclitaxel combined with other agents. Gemzar® has also shown anti-cancer activity in intensively pretreated and refractory patients with germ-cell cancer and is a reasonable palliative option.
High-dose chemotherapy with autologous blood stem cell support has been successful in producing long-term complete remissions in patients with refractory cancer. High-dose chemotherapy (HDC) kills more cancer cells than lower-dose conventional chemotherapy. Unfortunately, HDC also kills more normal cells, especially the blood-producing stem cells in the bone marrow. Stem cells are immature cells produced in the bone marrow that eventually develop into red blood cells, which provide oxygen to tissues; white blood cells, which fight infection; or platelets, which aid in blood clotting. The treatment strategy utilizing stem cell transplant is an attempt to restore the blood-producing stem cells after HDC has reduced them to dangerously low levels. When stem cells reach critically low levels from HDC, complications such as anemia, infection and bleeding can occur. Thus, it is imperative to restore stem cell levels as quickly as possible. Autologous stem cell transplants involve the collection of a patient’s own stem cells prior to chemotherapy treatment. These stem cells are frozen and then infused back into the patients after treatment to “rescue” the bone marrow.
In a recent clinical trial, researchers evaluated the novel treatment strategy involving two sequential doses of HDC and autologous stem cell transplants in patients with recurrent testicular cancer. All of these patients received HDC and autologous stem cell transplant as initial therapy following their recurrence. Three years following this treatment, almost 60% of these patients were cancer free.
Another large clinical study involving 150 patients evaluated high-dose Platinol®, etoposide and Ifex®. The chance of surviving without cancer recurrence was 29%, which may be greater than expected with non-stem cell supported conventional-dose therapy.
Strategies to Improve Treatment
The progress that has been made in the treatment of testicular cancer has resulted from improved development of chemotherapy and radiation treatments in patients with more advanced stages of cancer and participation in clinical trials. Future progress in the treatment of testicular cancer will result from continued participation in appropriate clinical trials. Currently, there are several areas of active exploration aimed at improving the treatment of relapsed/refractory testicular cancer.
Supportive Care: Supportive care refers to treatments designed to prevent and control the side effects of cancer and its treatment. Side effects not only cause patients discomfort, but also may prevent the optimal delivery of therapy at its planned dose and schedule. In order to achieve optimal outcomes from treatment and improve quality of life, it is imperative that side effects resulting from cancer and its treatment are appropriately managed. For more information, go to Supportive Care.
New Chemotherapy Regimens: Development of new multi-drug chemotherapy treatment regimens that incorporate new or additional anti-cancer therapies for use as treatment is an active area of clinical research carried out in phase II clinical trials.
High-Dose Chemotherapy with Stem Cell Support: Different high-dose chemotherapy regimens are being evaluated in patients with refractory disease. There are also trials of sequential administration of more than one high-dose regimen.
Phase I Trials: New chemotherapeutic agents continue to be developed and evaluated in phase I clinical trials. The purpose of phase I trials is to evaluate new drugs in order to determine the best way of administering the drug and whether the drug has any anti-cancer activity in patients.