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Chemotherapy is a standard treatment for many cancers, including testicular cancer. But, for patients with metastatic testicular cancer, where cancer has spread to the lymph nodes, liver, or lungs, for example, combination chemotherapy or high-dose chemotherapy may be needed.
Combination chemotherapy consists of two treatment regimens: BEP (bleomycin, etoposide, and cisplatin) and VIP (etoposide, ifosfamide, and cisplatin). Which regimen metastatic testicular cancer patients receive depends on individual patient features, particularly the status of their lungs. For example, older patients or smokers with poor lungs may have issues with the BEP regimen, which is an outpatient treatment, and may be treated with VIP, which is more involved and requires a hospital stay, or four cycles of etoposide and cisplatin, depending on the extent of their metastases.
Patients usually receive three cycles of three drugs over the course of three weeks for a total of nine weeks, but may undergo four cycles of combination therapy depending on their risk level. Testicular cancer patients are categorized as "good," "intermediate," or "poor" risk depending on the height of their tumor markers, such as the hormone human chorionic gonadotropin (HCG), after the removal of the testicle (orchiectomy), and the location of their metastases. For example, a good risk patient may have a HCG level of 50 and lung metastases, while a poor risk patient may have an HCG level of 60,000 and metastases in the liver. Good risk patients are usually treated with three cycles of BEP, or four cycles of etoposide, and cisplatin if they do not respond well to bleomycin, while intermediate and poor risk patients receive four cycles of either VIP or BEP.
Chemotherapy is very effective in treating testicular cancer patients. Good risk patients who undergo combination chemotherapy for three cycles have a cure rate of more than 95 percent. Those patients categorized as intermediate risk have a 75-80 percent cure rate after four cycles of treatment and poor risk patients have a 60 percent cure rate after four cycles.
The side effects of combination chemotherapy are similar to those of standard chemotherapy, including hair loss and infection risk, and relate to the toxicity and time commitment of the treatment. These acute side effects, including nausea, vomiting, and fatigue, can usually be managed with medications and lifestyle changes. Other side effects may include kidney, hearing, and nerve issues, but less than one in 20 patients require inpatient treatment because of good supportive care programs for combination chemotherapy side effects.
As the majority of testicular cancer patients are between the ages of 20 and 40, most manage acute side effects well, but long-term effects may also be a concern. For men in their twenties, there is a small potential of a second cancer or cardiovascular disease developing in the long term, which is why it is important to maintain a healthy lifestyle, including a nutritious diet, exercise, and not smoking. These men are also encouraged to bank sperm before treatment, as chemotherapy can have an impact on sperm counts. Men who have questions about or trouble with fertility after treatment can access Dana-Farber's Sexual Health Program for support and resources. Doctors will monitor patients for several years after treatment to ensure they are maintaining a healthy lifestyle and to mitigate any risks for late effects of chemotherapy, while watching for the rare relapse or second primary cancer that may develop.
Testicular cancer patients whose cancer relapses after combination chemotherapy are still curable through salvage chemotherapy or salvage high-dose chemotherapy.
Salvage chemotherapy consists of three weeks of four cycles of three drugs, such as TIP, a combination of paclitaxel, ifosfamide, and cisplatin, while salvage high-dose chemotherapy involves two cycles of TIP and an additional two cycles of high-dose treatment, which takes approximately three months to complete.
Patients rarely need high-dose chemotherapy as few people progress to this stage after standard combination chemotherapy. Although it is an intense regimen, it is curative with a medical team and facility with high-dose chemotherapy and bone marrow transplant expertise, such as Dana-Farber. During high-dose chemotherapy, the medical team uses peripheral blood stem cells to repopulate bone marrow after treatment, which requires longer hospital stays and increased monitoring, and often involves intensified side effects.
Metastatic patients who receive high-dose chemotherapy have a cure rate of 70 percent to 30 percent, depending on their risk level.
Testicular cancer, while rare, remains very curable, especially when caught in its earlier stages when orchiectomy, or removal of the testicle, may be the only treatment necessary. Those more advanced patients who do need chemotherapy or whose cancer has spread to other organs, should speak with their care team about what treatment option is best for them. Learn more about chemotherapy and what you can expect when starting treatment, or visit the Lank Center for Genitourinary Oncology for more information on testicular cancer.