It was performed through the network of the Global Germ Cell Cancer Group and it was a retrospective data analysis and collection. The main findings were that the outcome of men with relapse after adjuvant BEP is actually worse in comparison to patients with chemo-naive metastatic disease. However, it’s still better compared to patients who relapsed after having received chemo for metastatic disease.

We also found a substantial rate of late and subsequent relapses; quite remarkable was 29% of relapses occurring more than three years after adjuvant treatment and the latest even occurring 25 years after adjuvant treatment. 29% of the patients had subsequent relapses.

What could be the clinical implications of this treatment strategy?

The main thing is that you keep this in mind in the future. We would not recommend continuing follow-up after adjuvant BEP for all patients, of course, because the relapse rate is so low. But it’s important to keep it in mind if a patient presents after a long time and he has had adjuvant BEP for nonseminoma some time ago that you keep it in mind. It could be a recurrent germ cell cancer that you go for a proper biopsy and seek specialist pathology review to ask for differential diagnosis of a recurrent germ cell cancer.

How effective is this treatment strategy for relapsing patients?

We can’t really recommend one clear treatment strategy. In our analysis we found a remarkable diversity which underlines the uncertainty how to manage this situation. But we think rather going for a slight intensification and choosing a three drug regimen and giving 3-4 cycles with a replacement of bleomycin by ifosfamide could at least be considered and discussed with patients.

Why do you think the outcome was worse for de novo metastatic patients?

We have a negative selection of course. We only focused on those with a relapse so it might be we have a biologically unfavourable patient collection who have chemo-refractory disease in the end. But the main reason will be a negative selection.

When interpreting it it is, of course, important to bear in mind that we have this negative selection and this does not affect the overall very good outcome for all patients in the general population receiving adjuvant BEP. So it should not be misinterpreted that our data influences the general good outcome; it’s just like the selection of patients with relapse and we wanted to give a bit of clinical advice on this rare situation but our data does not influence the general good outcome after adjuvant BEP.