Testicular Cancer: Changing Tides

Prior to 1974, localized testicular cancer was easily cured with orchiectomy, while metastatic disease was effectively a death warrant – cure rates were as low as 5% with a variety of chemotherapeutic agents. This trial, conducted by an up-and-coming researcher using an experimental drug called cis-diamminedichloroplatinum (or as we know it, cisplatin), provided a much-needed win in the battle against solid cancers. From 1974-1976, Lawrence Einhorn used a combination of cisplatin, vinblastine and bleomycin to treat patients with mild to severe metastatic disease. Some patients received adjunct surgery to remove residual tumors. Overall, at the time of publication, 38 of 47 patients were disease free. Moreover, at 13-year follow-up (which is remarkable in and of itself), over 50% of patients were disease free, an achievement stated as a “one-log increase in the cure rate.”

In addition to improved cure rates, cisplatin did not cause a pronounced myelosuppression like other chemotherapeutic drugs. It was not without its vices though. As Einhorn described, platinum had toxic effects on the kidney, manifested as a 25-50% reduction in baseline creatinine clearance. This was likely exacerbated by the dehydration caused by the intractable nausea and vomiting, which is eloquently described in Mukherjee’s Emperor of All Maladies. From a critical perspective, the study was well conducted in the context of a limited number of patients. Criteria for partial versus complete remission were well-defined, and follow-up was more than sufficient. Additional trials in the following years would cement the new findings.

Although partial results had been published in reports in Journal of Urology and American Family Physician, the complete results of the trial were ultimately published in Annals of Internal Medicine in 1977.  Given the overwhelmingly positive response to the therapy and the aggressive nature of non-seminomatous testicular cancer, it was quickly approved by the FDA in 1978 and became the standard of care. The combination chemotherapy was modified in the 80s to use etoposide instead of vinblastine, leading to additional improvements in cure rates. That same combination is in use today, and cure rates exceed 95%. Moments like this, when one can claim a logarithmic increase in cure rates, are few and far between in medicine.

Einhorn LH, Donohue J. Cis-diamminedichloroplatinum, vinblastine, and bleomycin combination chemotherapy in disseminated testicular cancer. Ann Intern Med. 1977. Sep;87(3):293-8.

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A Brief Introduction

Welcome to Why We Do What We Do: A Guide to Landmark Studies in Medicine, a blog designed to showcase and discuss historically significant research studies that altered the landscape of medicine. Our goal is to create an arena, a virtual journal club of sorts, where medical students, MDs, healthcare professionals and even the casual reader can get a glimpse into the history behind the defining moments of medicine.

This is in no way a chronological compendium of clinical medicine; the posts are in no specific order, much like the clinical vignettes you may find published in medical journals. This is a means to pique your interest in the history behind our clinical algorithms and standard practices. In turn, I hope you gain a new appreciation for the MD-cum-novelist such as Siddhartha Mukherjee, Abraham Verghese or Allan Hamilton who have written at length on some of these same topics. Ultimately, we strive to familiarize you with the primary source for select, critical moments in medicine – those so blandly described in medical textbooks through which many of us have suffered. In our short clinical experience, curiosity got the best of us. Didn’t you ever wonder why we do what we do?