The use of salvage chemotherapy for patients with relapsed testicular germ cell tumor in Canada: A national survey
Esmail Al-Ezzi1, Carlos Stecca1, Robert J. Hamilton2, Michael Crump1, John Kuruvilla1, Lori A. Wood3, Lucia Nappi4, Christian Kollmannsberger4, Scott North5, Eric Winquist6, Denis Soulieres7, Sebastien Hotte8, Srikala S. Sridhar1, Di Maria Jiang1.
1Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada; 2Division of Urology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada; 3Division of Medical Oncology and Hematology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada; 4Department of Medicine, British Columbia Cancer Agency, University of British Columbia, Vancouver, BC, Canada; 5Division of Medical Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada; 6Department of Oncology, London Health Sciences Centre, Western University, London, ON, Canada; 7Département Hématologie-Oncologie, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; 8Department of Oncology, Juravinski Cancer Centre, McMaster University, Hamilton, ON, Canada
Introduction: Although metastatic germ cell tumor (GCT) is highly curable, 10% of patients relapse after initial cisplatin-based chemotherapy and have a poorer prognosis. Salvage chemotherapy options include conventional (CDCT) and high-dose chemotherapy (HDCT). However, definitive comparative data are lacking. We aimed to characterize the contemporary practice patterns of salvage chemotherapy across Canada.
Methods: We conducted a 30-question online survey in August 2021 on medical (MO) and hematological oncologists (HO) with experience in treating GCT, assessing treatment availability, patient selection, and management strategies used for relapsed GCT patients.
Results: Respondents were 24 staff MO, 2 HO, 2 both; from British Columbia, Alberta, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia, and PEI; 86% were from academic centers. Reported case volumes for salvage chemotherapy were <1 (18%), 1 (21%), 1–5 (39%), and 6–10 cases/year (21%). No active clinical trials were available at the time of the survey. The most common CDCT regimens used were TIP (64%) and VIP (25%). HDCT was available for 70%, and used as first- (67%, range 0–100), second- (33%, 0–100) or third-line/beyond (4%, 0–20) salvage therapy. Only some used the IPFSG risk classification for treatment selection (Table 1). Assuming tolerability and feasibility, only one respondent indicated a clinical scenario precluding HDCT ("rising markers during platinum chemotherapy for mediastinal non-seminoma"). HDCT regimen used included carboplatin and etoposide (two cycles 76%; three cycles 6%), and the TICE protocol (two centers). “Bridging” CDCT was needed by 63% while waiting to access HDCT. Post-HDCT treatments considered include surgical resection for residual disease (n=13), maintenance etoposide (n=1), and surveillance only (n=1).
Conclusions: HDCT is the most commonly used GCT salvage strategy in Canada. Significant differences exist in the treatment availability, selection, and delivery of HDCT, highlighting the need for standardization of care for patients with relapsed testicular GCT requiring salvage chemotherapy.
| Treatment selection based on IPFSG risk classification | (%) |
| Not familiar with IPFSG | 19 |
| HDCT regardless of IPFSG | 33 |
| CDCT only for IPFSG very low and low risk | 26 |
| CDCT for only IPFSG low risk | 15 |
| CDCT regardless of IPFSG | 0 |
| Other | 7 |
