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The Sword of Damocles and the Treatment of Stage I Seminoma

St Barts and the London Hospital Medical School, London, United Kingdom

To the Editor:

While we support Drs Loehrer and Bosl's view that a physician's prime responsibility is In Primum non Noce (ie, above all do no harm), we are less supportive of what they say in their editorial.¹ We would certainly agree that patients treated with adjuvant carboplatin have not, as of yet, been observed for the 30 years that was necessary to demonstrate the 18% excess risk after standard radiation therapy (ie, 25 to 30 Gy dog leg field) of dying from a cardiovascular or non–germ cell malignant event.² However, neither have patients being treated with the newer less intense radiotherapy schedules that Loeher and Bosl recommend uncritically, such as 20 Gy to para-aortics (PA) only,^3,4 and recent reports have raised some concern about an increased incidence of late recurrences in these patients.^4,5

It is certainly untrue to say that no randomized trials comparing carboplatin with radiotherapy have been performed. The definitive Medical Research Council (MRC) trial TE 19/European Organisation for the Research and Treatment of Cancer 30982 trial reported to the American Society of Clinical Oncology in 2004, and published in full in 2005⁶ randomly assigned 1,477 patients between radiation and one course carboplatin and demonstrated the clinical equivalence of these two approaches. This, the largest randomized trial ever conducted in testicular cancer, seems to have escaped Loehrer and Bosl's notice.

Carboplatin has also clearly established itself in the MRC TE19 trial as less toxic than even the new schedules of radiation in the short term. It was also shown in that trial to have the added advantage of a 72% reduction in the risk of second germ cell cancers in the contralateral testis at 5 years⁶ compared with radiation. The latest reports from follow-up of carboplatin phase II studies in stage I seminoma⁷ that we reported to the American Society of Clinical Oncology in 2005 plus the data from the MRC TE19 trial⁶ are summarized in Table 1. This Table presents in an analysis of 1,654 patients that only one patient observed for more than 36 months after treatment has relapsed and 415 have been observed for 5 years and 82 observed for 10 years.

Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

1. Loehrer PJ, Bosl GJ: Carboplatin for stage I seminoma and the sword of Damocles. J Clin Oncol 23:8566-8569, 2005[Free Full Text]

2. Zagars GK, Ballo MT, Lee AK, et al: Mortality after cure of testicular seminoma. J Clin Oncol 22:640-647, 2004[Abstract/Free Full Text]

3. Jones WG, Fossa SD, Mead GM, et al: Randomized trial of 30 versus 20 Gy in the adjuvant treatment of stage I testicular seminoma: A report on Medical Research Council Trial TE18, European Organisation for the Research and Treatment of Cancer Trial 30942 (ISRCTN18525328). J Clin Oncol 23:1200-1208, 2005[Abstract/Free Full Text]

4. Logue JP, Harris MA, Livsey JE, et al: Short course para-aortic radiation for stage I seminoma of the testis. Int J Radiat Oncol Biol Phys 57:1304-1309, 2003[CrossRef][Medline]

5. Oliver RTD: One-dose carboplatin in seminoma. Lancet 366:1526, 2005

6. Oliver T, Mason MD, Mead GM, et al: Radiotherapy versus singe-dose carboplatin in adjuvant treatment of stage 1 seminoma: A randomised trial. Lancet 366:293-300, 2005[CrossRef][Medline]

7. Oliver TD, Steiner K, Skoneczna H, et al: Pooled analysis of phase II reports of 2 vs. 1 course of carboplatin as adjuvant for stage 1 seminoma. J Clin Oncol 23:395s, 2005 (suppl; abstr 4572)

8. Oliver RTD: Risking less treatment in cancer patients: Lessons from germ-cell tumours. Lancet 2:430-431, 1988[CrossRef][Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Oliver, T. Articles by Kratzik, C. Search for Related Content PubMed PubMed Citation Articles by Oliver, T. Articles by Kratzik, C. Social Bookmarking                            What's this?