EURURO Vol. 72 No. 5

857 860

A technology that allows fast teaching with good
functional and oncological results in a short period of time
should be considered a great improvement, not only for
patients but also for health care systems.
Conflicts of interest: The author has nothing to disclose.
References
[1]
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[2]
[3]
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Maurizio Brausi*
Department of Urology, B. Ramazzini Hospital, Carpi-Modena, Italy
*Department of Urology, B. Ramazzini Hospital, Via G. Molinari,
41012 Carpi-Modena, Italy.
E-mail address: .
© 2017 European Association of Urology.
Published by Elsevier B.V. All rights reserved.
Re: Multi-institutional Assessment of Adverse Health
Outcomes Among North American Testicular Cancer
Survivors After Modern Cisplatin-based Chemotherapy
Fung C, Sesso HD, Williams AM, et al
J Clin Oncol 2017;35:1211–22
Experts’ summary:
This contemporary, cross-sectional investigation of 952 testic-
ular cancer (TC) survivors cured after four cycles of etoposide
and cisplatin (EPX4, n = 294) or three or four cycles of bleo-
mycin, etoposide, cisplatin (BEPX3, n = 364; BEPX4, n = 170)
evaluated for the type and prevalence of adverse health out-
comes (AHOs). At median time from chemotherapy of 4.3 yr,
the median number of AHOs in both the EPX4 and BEPX3
groups was two, with 34.3% and 35.1% of survivors, respec-
tively, reporting three or more AHOs. While the most common
AHOs including tinnitus and hearing impairment were similar
between the groups, there were significant differences in the
AHO type and incidence between the EPX4 and BEPX3 groups
for Reynaud's phenomenon (11.6% vs 21.4%; p < 0.01), periph-
eral neuropathy (29.2% vs 21.4%; p = 0.02), and obesity (25.5%
vs 33%; p = 0.04). Increasing age and current smoking were
associated with higher AHO rates, while exercise provided a
protective effect.
Experts’ comments:
Owing to excellent cure rates in metastatic TC, minimizing
treatment-related morbidity is paramount. For patients with
a good risk profile, some strategies to lessen adverse effects
have been successful, such as elimination of a fourth BEP
cycle, but others failed, such as attempts to substitute car-
boplatin for cisplatin [1,2]. In an effort to avoid bleomycin-
associated toxicity, Culine et al [3] directly compared EPX4
and BEPX3. The primary endpoint of favorable response
(94.7% vs 96.8%) and secondary endpoints of event-free
survival (91% vs 86%) and 4-yr overall survival (97% vs
93%) were not significantly different between the groups.
The National Comprehensive Cancer Network endorses EPX4
or BEPX3 for TC patients with a good risk profile [4], although
the equal efficacy of EPX4 and BEPX3 is not uniformly ac-
cepted [5].
There is a paucity of data on the impact of an additional
cycle of EP (in patients receiving EPX4) or of potentially
synergistic adverse effects of bleomycin and cisplatin (in
patients receiving BEPX3) on late adverse consequences in
TC survivors. Fung et al highlight differential toxicity
profiles for these two commonly used regimens. Impor-
tantly, cumulative bleomycin doses were significantly
associated with five or more AHOs, whereas cumulative
cisplatin doses were not. Bleomycin-associated pulmonary
toxicity was not assessed. Furthermore, patients were not
stratified by receipt of post-chemotherapy retroperitoneal
lymph node dissection, which was performed in 48% of
patients and could impact AHOs. As these data mature,
critical information regarding cardiovascular toxicity and
secondary malignancy will also arise, influencing the
debate on optimal treatment for favorable-risk TC.
Conflicts of interest: The authors have nothing to disclose.
References
[1]
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[2]
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[3]
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