TESTIS CANCER
1389
Urological Oncology: Testis Cancer Pulmonary Function in Long-Term Survivors of Testicular Cancer H. S. Haugnes, N. Aass, S. D. Fossa, O. Dahl, M. Brydoy, U. Aasebo, T. Wilsgaard and R. M. Bremnes Department of Oncology, Institute of Clinical Medicine, University of Tromso, Tromso, Norway J Clin Oncol 2009; 27: 2779 –2786.
Purpose: Long-term toxicity after cancer treatment has gained increasing clinical attention. We evaluated pulmonary function in long-term survivors of testicular cancer (TC). Patients and Methods: The pulmonary function of 1,049 TC survivors treated during 1980 to 1994 at three university hospitals in Norway was assessed by spirometry and a questionnaire (1998 to 2002). The patients were categorized into five treatment groups, as follows: surgery only (n ⫽ 202); radiotherapy only (n ⫽ 449); chemotherapy (cisplatin ⱕ 850 mg; n ⫽ 306); chemotherapy (cisplatin ⬎ 850 mg [higher-dose group]; n ⫽ 62); and chemotherapy and pulmonary surgery (cis/pulmsurg; n ⫽ 30). Spirometry variables included forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Actual values and percentages of predicted normal values (FVC%pred and FEV1%pred, respectively) are reported. Restrictive lung disease was defined as FEV1/FVC ⱖ 70% and FVC%pred less than 80%. Results: Median observation time was 11.2 years (range, 5 to 21 years). Compared with the surgery group, the higher-dose or cis/pulmsurg groups had considerably lower age-adjusted FVC (higher-dose: beta ⫽ ⫺.37; P ⫽ .001; cis/pulmsurg: beta ⫽ ⫺.58; P ⬍ .001), FEV1 (higher-dose: beta ⫽ ⫺.24; P ⫽ .014; cis/pulmsurg: beta ⫽ ⫺.55; P ⬍ .001), FVC%pred (higher-dose: beta ⫽ ⫺8.3; cis/pulmsurg: beta ⫽ ⫺10.5; both P ⬍ .001), and FEV1%pred (higher-dose: beta ⫽ ⫺6.8; P ⫽ .003; cis/pulmsurg: beta ⫽ ⫺12.4; P ⬍ .001). Adjustment for total testosterone, body mass index, smoking, and physical activity did not change these associations. Eight percent of all patients had restrictive lung disease, and the highest prevalence was in the higher-dose group (17.7%) and the cis/pulmsurg (16.7%) group. Compared with patients who underwent surgery only, these groups had odds ratio for restrictive disease of 3.1 (95% CI, 1.3 to 7.3) and 2.5 (95% CI, 0.8 to 7.6), respectively. Conclusion: Large doses of cisplatin-based chemotherapy and combined chemotherapy/ pulmonary surgery are significantly associated with decreased pulmonary function several years after TC treatment. Editorial Comment: With the advent of cisplatin based chemotherapy, especially bleomycin, the cure rate for testicular cancer now exceeds 95%. However, bleomycin may cause pneumonitis, which may occasionally progress to pulmonary fibrosis. A recent study demonstrated significantly increased mortality as a result of respiratory disease among chemotherapy treated testicular cancer survivors compared to the general population. The authors have evaluated a large group of more than 1,000 testicular cancer survivors in Norway, and assessed their pulmonary function by spirometry and questionnaire. Patients who received chemotherapy were compared to those who underwent surgery or radiation therapy alone. The chemotherapy groups had lower age adjusted forced vital capacity and FEV1. The authors conclude that large doses of cisplatin based chemotherapy are associated with a significant decrease in pulmonary function years after treatment for testicular cancer. Jerome P. Richie, M.D.