Novel Treatment Strategies and Stem Cell Transplantation - Episode 1

Navigating Through Testicular Cancer Treatment


Nabil Adra, MD: My name is Dr Nabil Adra. I’m an assistant professor of medical oncology at IU [Indiana University] Health.

Testicular cancer is the most common cancer among young men, usually ages 15 to 35. Patients who are diagnosed with metastatic testicular cancer are usually cured with cisplatin-based combination chemotherapy. The cisplatin-based combination chemotherapy regimens were pioneered here at Indiana University over 40 years ago. Unfortunately, about 20% of patients with metastatic testicular cancer relapse after first-line combination chemotherapy.

For those patients with relapsed testicular cancer who have anatomically confined disease, we usually recommend surgical resection by an expert urologist. However, the majority of these patients will relapse with advanced disease, possibly with rising tumor markers.

For those patients, our preference and recommendation at IU Health is to proceed straight to high-dose chemotherapy and peripheral blood stem cell transplant.

We are treating patients with relapsed testicular germ cell tumors with high-dose chemotherapy and peripheral blood stem cell transplant. This approach started at Indiana University in 1986, when they were using bone marrow transplant for those patients, and we showed that we were able to cure a certain number of patients using this technique.

In 1996, peripheral blood stem cell transplants replaced bone marrow transplants, allowing for more effective delivery of this treatment and allowing us to achieve better cure numbers.

In our first series of 184 consecutive patients, which was published in the New England Journal of Medicine, we showed that when high-dose chemotherapy is used in the second-line setting, we’re able to cure about 70% of patients with relapsed testicular cancer. And when this is used in the third-line setting, or subsequent setting, we’re able to cure about 45% of patients with relapsed testicular cancer.

We think that high-dose chemotherapy is effective in those patients because we know that testicular germ cell tumors are chemotherapy-sensitive tumors. The majority of those patients are cured with first-line cisplatin-based combination chemotherapy. For the minority of patients who are not cured with first-line chemotherapy, it’s not a matter that those tumors were not sensitive to chemotherapy. It’s a matter that we think those patients don’t get enough intensity of chemotherapy. That’s why our preference is to move to high-dose chemotherapy in this patient population.

I think testicular cancer is a success story in oncology. For the majority of patients, we are able to cure those patients with first-line chemotherapy. However, patients with relapsed testicular cancer have very complicated clinical scenarios. Those patients typically have rapidly progressive disease and tend to be quite sick. Our recommendation at Indiana University Health is that those patients be seen at a Center of Excellence for testicular cancer, such as our center at Indiana University Health.

A multidisciplinary approach is very important; and most importantly, moving very quickly to high-dose chemotherapy and peripheral blood stem cell transplants, therefore, achieving the best chance of curing those patients. In addition, it’s very important to offer modern supportive care for those patients while they are receiving high-dose chemotherapy and stem cell transplant, to lower the complication rate of this high-dose chemotherapy.

We at Indiana University Health were the first to treat patients with relapsed testicular cancer with high-dose chemotherapy and stem cell transplant. We have over 30 years of experience with those treatments, and we have treated more patients than any other center with high-dose chemotherapy for relapsed testicular cancer. Over those years, we have perfected the use of high-dose chemotherapy and have learned how to navigate the treatment, the toxicity, and the long-term outcomes of those treatments.

We have a strong collaboration with referring providers for patients with relapsed testicular cancer. Typically, we see patients very quickly after they are referred here to Indiana University Health. If needed, we proceed very quickly to high-dose chemotherapy. Once patients are treated and complete their high-dose chemotherapy, we send those patients back to their referring oncologist so that they can continue their follow-up locally, or closer to their homes.

Providing optimal treatment for those patients will hopefully achieve cure and allow those patients to live their normal lives, which could be 40, 50, 60, and sometimes 70 more years of life. I think that this makes testicular cancer a unique situation. Patients are targeting cure, and not just prolongation of life.

Our overall goal at Indiana University Health is to offer the best advances for patients with testicular cancer. From new biomarkers in patients with localized disease and early stage disease, to high-dose chemotherapy and stem cell transplant in patients with relapsed testicular cancer, to new clinical trials evaluating new drugs for refractory patients with testicular cancer, our goal is to cure every patient with testicular cancer.

Transcript Edited for Clarity