Dose intensity in germ cell cancer: continued lessons from a model neoplasm

Clinical trials of chemotherapy in germ cell cancer have explored the full range of dose intensity. In good risk patients, efforts have been successful in diminishing duration of treatment or number of drugs required to cure the illness reliably. In patients with poor prognosis, efforts to intensify therapy have been undertaken. It has been difficult to demonstrate improved outcome using higher doses of conventional agents in the setting of primary treatment of poor risk disease. It is more likely that improvement will come with the discovery of new active agents. High dose chemotherapy with bone marrow or peripheral blood stem cell support can cure a small portion of selected patients with multiple recurrences of germ cell cancer. The impact of earlier treatment with high dose chemotherapy as initial salvage therapy or even primary treatment is less certain. Clinical trials in these settings have not yet demonstrated a definite advantage over less toxic conventional dose therapies.