How to Optimize Treatment for Patients With Poor-Risk Testicular Cancer

Male germ cell tumors, of which testicular is the most common, are rare but generally highly curable malignancies. Cure rates in the metastatic setting are among the highest for any solid tumor, although outcomes in the poor-risk subgroup remain suboptimal. Although most men are cured, risk prognostication tools have identified poor-risk patients with inferior outcomes leading to significant mortality in this predominantly young patient population. To optimize survival in this group, proper therapy selection throughout the treatment course of poor-risk patients is vital to maximize survival opportunities. Established first-line therapies are available requiring expertise in their selection and toxicity management. Surgical evaluation remains vital for poor-risk patients to address unique disease characteristics seen in this population including multifocal residual disease, extensive mediastinal disease, and brain metastases. Salvage systemic therapies have been developed with several options of conventional and high-dose chemotherapy, requiring expertise in patient selection and treatment delivery. This review discusses the treatment landscape of poor-risk patients, systemic therapy selection, surgical evaluation of patients, treatment of brain metastases, and contemporary management strategies of pertinent clinical scenarios highlighting the multidisciplinary approach needed to optimize cure rates in this group.