Management of good risk germ-cell tumours

Following the implementation of cisplatin-containing combined chemotherapy, patients with good-risk metastatic germ-cell cancer have an excellent prognosis. Since the 1980s, bleomycin, etoposide and cisplatin (BEP) have become the standard chemotherapy regimen for these patients. In view of both the high curative potential of BEP chemotherapy and the treatment-related side-effects, trials were carried out in patients with the greatest chance of cure to develop regimens with an improved toxicity profile while maintaining efficacy. Following the results of these trials, the standard chemotherapy in good-risk disease has been reduced from four cycles of BEP (4BEP) to three cycles of BEP (3BEP). Four cycles of etoposide and cisplatin (4EP) is an alternative treatment regimen, with similar efficacy. Studies that explored additional adjustments in the BEP regimen to further decrease toxicity have shown that the lower threshold of efficacy has been reached, and that the efficacy of the chemotherapy is compromised. Especially during the last decade, important long-term side-effects after the treatment of germ-cell cancers have been recognized. Chemotherapy in patients with germ-cell cancer increases the risk of developing cardiovascular disease and second malignant neoplasms. Whether 3BEP or 4EP is the optimal chemotherapy regimen for the future remains to be identified. Possibly differences in acute and late toxicities attributed to chemotherapy might eventually identify the best strategy.