A randomised phase III study of 72 hour infusional versus bolus bleomycin in BEP (bleomycin, etoposide and cisplatin) chemotherapy to treat IGCCCG good prognosis metastatic germ cell tumours (TE-3)

Background: Bleomycin is an integral part of combination chemotherapy in germ cell tumours. Pulmonary toxicity often necessitates drug cessation and death occurs in 1-2% of patients. A continuous infusion of bleomycin might reduce lung toxicity when compared to the conventional weekly boluses given as part of standard BEP chemotherapy.
Patients and Methods: A phase 3 randomised trial was conducted. Two hundred and twelve men with IGCCCG good prognosis metastatic germ cell tumours were randomized in a 1:1 fashion. They were stratified for age, smoking history and renal function. Patients received either conventional BEP with weekly bleomycin (30000 units /week IV bolus) or as a 90000 unit infusion on day 1 over 72 hours. The primary endpoint was CT assessed lung toxicity, secondary endpoints included PFS, changes in lung function testing and quality of life. Repeated measures mixed effects model was used to analyse the data.
Results: CT assessed lung toxicity for the infusional and conventional arm patients were respectively 80% versus 62% at the end of treatment and 54% versus 51% at one year post treatment. There was no significant difference between the two arms for CT assessed lung toxicity (estimated regression coefficient (difference) =1.4, P=0.9, 95% CI:-0.36, 3.16). Older patients had higher toxicity (coefficient=4.81, 95% CI: 3.04, 6.58). Lung toxicity increased after 1 cycle and peaked at end of treatment (P≤0.002) and then declined. Lung function testing failed to show any differences between the two arms, and did not predict for subsequent lung damage. The median follow-up was 2.5 years. Two-year PFS rate (infusional arm= 93% versus conventional arm=94%; hazard ratio =0.91, 95% CI: 0.33, 2.52) was not significantly different. Cough (P=0.002) but not shortness of breath (P≥0.09) was associated with bleomycin toxicity.
Conclusions: Infusional bleomycin has no advantage over standard administration. It supports abandoning routine pulmonary function testing, instead the presence of cough should be sought and the early use of CT scanning of the chest to evaluate potential lung toxicity is preferred.