Originally published as JCO Early Release 10.1200/JCO.2008.18.8953 on March 23 2009

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Risk-Adapted Treatment in Clinical Stage I Nonseminomatous Germ Cell Testicular Cancer: The SWENOTECA Management Program

From the Department of Oncology, St Olavs University Hospital, Trondheim; Department of Oncology, Haukeland Hospital and Section of Oncology, Institute of Medicine, University of Bergen, Bergen; Cancer Center, Ullevål University Hospital, Oslo; Department of Oncology, University Hospital of Northern Norway and University of Tromsø, Tromsø; Department of Oncology, Ålesund Hospital, Ålesund, Norway; Department of Oncology, Karolinska University Hospital, Stockholm; Department of Oncology, Lund University Hospital, Lund; Department of Oncology, Sahlgrenska University Hospital, Gøteborg; Department of Oncology, Uppsala University Hospital, Uppsala; and the Department of Urology, Karolinska University Hospital, Huddinge, Sweden.

Corresponding author: Torgrim Tandstad, MD, Department of Oncology, St Olavs University Hospital, Olav Kyrres gt 17, 7006 Trondheim, Norway; e-mail: torgrim.tandstad{at}stolav.no.

Purpose To offer minimized risk-adapted adjuvant treatment on a nationwide basis for patients with clinical stage 1 (CS1) nonseminomatous germ-cell testicular cancer (NSGCT). The aim was to reduce the risk of relapse and thereby reducing the need of later salvage chemotherapy while maintaining a high cure rate.

Patients and Methods From 1998 to 2005, 745 Norwegian and Swedish patients were included into a prospective, community-based multicenter Swedish and Norwegian Testicular Cancer Project (SWENOTECA) management program. Treatment strategy depended on the presence or absence of vascular tumor invasion (VASC). VASC-positive patients were recommended brief adjuvant chemotherapy (ACT) with bleomycin, etoposide, and cisplatin (BEP), whereas VASC-negative patients could choose between ACT and surveillance.

Results At a median follow-up of 4.7 years, there have been 51 relapses. On surveillance, 41.7% of VASC+ patients relapsed, compared with 13.2% of VASC– patients. After one course of BEP, 3.2% of VASC+ and 1.3% of VASC– patients relapsed. The toxicity of adjuvant BEP was low. Eight patients have died, none died from progressive disease.

Conclusion One course of adjuvant BEP reduces the risk of relapse by approximately 90% in both VASC+ and VASC– CS1 NSGCT, and may be a new option as initial treatment for all CS1 NSGCT. One course of adjuvant BEP for VASC+ CS1 reduces the total burden of chemotherapy compared with surveillance or two courses of BEP. SWENOTECA currently recommends one course of BEP as standard treatment of VASC+ CS1 NSGCT, whereas both surveillance and one course of BEP are options for VASC– CS1 NSGCT.

Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

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