title: Population-based study of treatment guided by tumor marker decline in patients with metastatic nonseminomatous germ cell tumor: a report from the Swedish-Norwegian Testicular Cancer Group.
abstract: OBJECTIVE
  From 1995 to 2003, 603 adult patients from Sweden and Norway with metastatic testicular nonseminomatous germ cell tumor (NSGCT) were included prospectively in a population-based protocol with strict guidelines for staging, treatment, and follow-up. Patients with extragonadal primary tumor or previous treatment for contralateral testicular tumor were excluded. The basic strategy was to individualize treatment according to initial tumor marker response.
  
  
  METHODS
  Initial treatment for all patients was two courses of standard bleomycin, etoposide, and cisplatin (BEP), with tumor markers analyzed weekly. Good response was defined as a half-life (t(1/2)) for α-fetoprotein (AFP) of ≤ 7 days and/or for β-human chorionic gonadotropin (β-HCG) of ≤ 3 days. Patients with prolonged marker t(1/2) (ie, poor response) received intensification with addition of ifosfamide (BEP-if/PEI) in step 1. If poor response continued, the treatment was intensified with high-dose chemotherapy with stem-cell rescue as step 2.
  
  
  RESULTS
  Overall, 99% of all patients with metastatic testicular NSGCT in the population were included in the protocol. Median follow-up was 8.2 years. Seventy-seven percent of the patients were treated with BEP alone; 18% received intensification step 1%, and 5% received intensification step 2. Grouped according to International Germ Cell Consensus Classification, 10-year overall survival was 94.7% in good-prognosis patients, 90.0% in intermediate-prognosis patients, and 67.4% in poor-prognosis patients.
  
  
  CONCLUSIONS
  With detailed treatment protocols and a dedicated collaborative group of specialists, treatment results comparable to those reported from large single institutions can be achieved at national level. With the treatment principles used in Swedish-Norwegian Testicular Cancer Group study SWENOTECA IV, the survival of intermediate-prognosis patients is remarkable and close to that of good-prognosis patients.
authors.affiliation: Lund University Hospital, Lund University, Lund, Sweden. sven-erik.olofsson@ltkronoberg.se
authors.forename: Sven-Erik
authors.initials: SE
authors.lastname: Olofsson
authors.forename: Torgrim
authors.initials: T
authors.lastname: Tandstad
authors.forename: Mats
authors.initials: M
authors.lastname: Jerkeman
authors.forename: Olav
authors.initials: O
authors.lastname: Dahl
authors.forename: Olof
authors.initials: O
authors.lastname: Ståhl
authors.forename: Olbjørn
authors.initials: O
authors.lastname: Klepp
authors.forename: Roy M
authors.initials: RM
authors.lastname: Bremnes
authors.forename: Gabriella
authors.initials: G
authors.lastname: Cohn-Cedermark
authors.forename: Carl W
authors.initials: CW
authors.lastname: Langberg
authors.forename: Anna
authors.initials: A
authors.lastname: Laurell
authors.forename: Arne
authors.initials: A
authors.lastname: Solberg
authors.forename: Ulrika
authors.initials: U
authors.lastname: Stierner
authors.forename: Rolf
authors.initials: R
authors.lastname: Wahlqvist
authors.forename: Hans
authors.initials: H
authors.lastname: Wijkström
authors.forename: Harald
authors.initials: H
authors.lastname: Anderson
authors.forename: Eva
authors.initials: E
authors.lastname: Cavallin-Ståhl
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use*; D014408:Biomarkers, Tumor / Q000032:analysis; D001761:Bleomycin / Q000627:therapeutic use; D002945:Cisplatin / Q000627:therapeutic use; D004334:Drug Administration Schedule; D005047:Etoposide / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008875:Middle Aged; D009362:Neoplasm Metastasis; D009373:Neoplasms, Germ Cell and Embryonal / Q000188:drug therapy / Q000401:mortality / Q000473:pathology; D009664:Norway; D011159:Population Surveillance; D011379:Prognosis; D013548:Sweden; D013736:Testicular Neoplasms / Q000188:drug therapy* / Q000401:mortality / Q000473:pathology
chemical_list: D014408:Biomarkers, Tumor; D001761:Bleomycin; D005047:Etoposide; D002945:Cisplatin