Vascular Access for BEP Regimen
Central venous access devices should be avoided whenever possible during BEP (Bleomycin, Etoposide, Cisplatin) chemotherapy, as they represent a significant risk factor for thromboembolic events. 1
Rationale for Peripheral Venous Access
The European Association of Urology (EAU) 2023 guidelines specifically address vascular access during chemotherapy for testicular germ cell tumors. The guidelines state that the majority of the expert panel agrees that central venous-access devices should be avoided whenever possible as they represent the only modifiable risk factor that remained significantly associated with venous thromboembolism (VTE) 1.
This recommendation is further supported by the ESMO-EURACAN 2022 guidelines, which also advise that vascular access devices (VADs) should be avoided whenever possible during chemotherapy for germ cell tumors 1.
Thromboembolic Risk with BEP
Patients receiving BEP chemotherapy are at particularly high risk for thromboembolic events:
- Patients with testicular germ cell tumors undergoing chemotherapy have significantly more thromboembolic events within the first year of treatment 1
- Risk factors include:
- Increasing disease stage
- Size of retroperitoneal lymph nodes (>3.5 cm)
- Presence of indwelling vascular access device 1
Thromboprophylaxis Considerations
If peripheral venous access is challenging and a central line becomes necessary, thromboprophylaxis should be considered:
- Prophylaxis should be considered for patients with:
- Retroperitoneal lymph nodes >3.5 cm
- Stage III disease
- Intermediate or poor-risk features
- Immobilization 1
- Exception: Patients with choriocarcinoma and high-volume extraperitoneal disease are at high risk of bleeding and may not be suitable for thromboprophylaxis 1
BEP Administration Considerations
The BEP regimen typically consists of:
- Cisplatin: 20 mg/m² days 1-5
- Etoposide: 100 mg/m² days 1-5
- Bleomycin: 30 mg on days 1,8, and 15 1
Given this schedule with multiple infusions over several days, adequate venous access is important but should be achieved through peripheral veins whenever possible.
Special Considerations
- Patients with poor venous access may require careful evaluation, but the risks of central venous access should be weighed against the benefits
- If a central line is absolutely necessary, aggressive thromboprophylaxis should be considered
- Patients with pulmonary dysfunction may receive VIP (etoposide, ifosfamide, cisplatin) instead of BEP, but the recommendation for peripheral access remains the same 1
Conclusion
When administering BEP chemotherapy for testicular cancer, peripheral venous access should be the standard approach to minimize thromboembolic complications. Central venous access devices should be avoided unless absolutely necessary, and if used, appropriate thromboprophylaxis should be considered based on individual risk factors.