Chemotherapy of metastatic testicular cancer: Current status and future prospects

Introduction of the chemotherapeutic agent cisplatin in 1974 initiated 15 years of progress in the management of metastatic testicular cancer at a pace virtually unprecedented in the history of medical oncology. With current cisplatin- and etoposide-based regimens, longterm survival of 80% is consistently achieved. Recently completed clinical trials have defined several prognostic variables that disthinguish good- and poor-prognosis subsets of patients. Since the great majority of patients with good-prognosis disease achieve complete remission and long-term survival, the current focus of research in this patient population has shifted to means of reducing treatment-related toxicity. By comparison, in poor-prognosis patients the cure rate remains an unacceptable 40%-50%. Clinical research in this population has focused primarily on methods of intensifying treatment, such as alternating non-cross-resistant drug combinations, increasing the dose intensity of cisplatin, and investigating new active agents such as ifosfamide. Even in the setting of relapsed or resistant disease, high-dose chemotherapy with or without autologous bone marrow transplant offers the potential for long-term remission in some patients. Future prospects for improving the therapeutic index may include colony-stimulating-factor support to circumvent chemotherapy-related myelosuppression, the use of chemosensitizers to reverse drug resistance, or the introduction of biologic response modifiers into the therapeutic armamentarium.