Barriers to cure in advanced non-seminomatous germ cell tumors: a clinical audit from a resource-limited region in India

Non-seminomatous germ cell tumors (NSGCT) are considered highly curable malignancies in developed nations. However, outcomes in low- and middle-income countries remain suboptimal, and literature describing outcomes and barriers to cure in advanced NSGCT from resource-limited settings is scarce. A retrospective analysis was conducted among patients with advanced NSGCT treated at a tertiary cancer center in central India. Primary endpoint was overall survival (OS), while secondary endpoints included progression-free survival (PFS), and treatment-related toxicity. Among 108 evaluated patients with testicular cancer, 60% had NSGCT and 51% had advanced disease. The median age was 28 years, and the median time from symptom onset to presentation was 5.5 weeks. Disease staging revealed 9% stage IIC, 6% stage IIIA, 24% stage IIIB, and 61% stage IIIC disease. Nearly half of the patients (49%) were underweight, and 45% had hypoalbuminemia. Treatment delays and/or dose modifications occurred in 81% of patients, primarily due to treatment-related toxicities. Hematologic toxicities were frequent, including grade 3–4 anemia (23%), neutropenia (19%), and febrile neutropenia (29%). There were two treatment-related deaths. At a median follow-up of 21 months, the median PFS and OS were 8.6 months and 11.9 months, respectively. Normal body mass index (BMI) was significantly associated with improved PFS (p = 0.03) and OS (p = 0.015). Outcomes for advanced NSGCT in this resource-limited setting were significantly inferior to those reported from high-income countries. Key contributing factors included delayed presentation, advanced disease at diagnosis, poor chemotherapy tolerance, and frequent treatment delays and dose modifications.