Trends in Testicular Cancer Survival: A Large Population-based Analysis

Causes of death among patients with testicular cancer during the survivorship

OBJECTIVE

The aim was to evaluate the causes of death for patients with testicular cancer (TC), and calculate mortality risks for each cause.

METHODS

Patients diagnosed between 2000 and 2017 were identified. Main causes of death including TC, second malignant tumor (SMT) and non-tumor diseases, and the standardized mortality rate (SMR) of each cause were analyzed.

RESULTS

27,143 patients with localized TC were included, and 1171 of them died including 215 TC deaths, 236 SMT deaths, and 720 non-tumor deaths. Main SMT deaths were cancer from lung and bronchus, colon and rectum, etc. Main non-cancer causes were diseases of heart, accidents and adverse effects and suicide and self-inflicted injury. Compared with the general population, the mortality risks from diseases of heart and accidents and adverse effects were significantly reduced. For 11,719 patients with regional and distant metastasis TC, 1733 died including 964 TC deaths, 345 SMT deaths and 424 non-tumor deaths. The main SMT and non-tumor deaths were lung and bronchus, diseases of heart and suicide and self-inflicted injury.

CONCLUSION

The leading causes of death besides TC were lung and bronchus cancer, colon and rectum cancer, diseases of heart, accidents and adverse effects, suicide and self-inflicted injury for TC patients. The localized TC patients were associated with similar risks of SMT deaths and lower risks of main non-tumor causes of death.

IMPACT

We evaluated all causes of death of TC patients and SMR for each cause of death. Our results could provide valuable information about the priority of healthcare during testicular cancer survival.

Emergency room imaging in patients with genitourinary cancers: analysis of the spectrum of CT findings and their relation to patient outcomes

PURPOSE

To assess the spectrum of computed tomography (CT) findings in patients with genitourinary cancers visiting the emergency room (ER) and evaluate the relationship between CT findings and overall survival (OS).

METHODS

Retrospective analysis of consecutive patients with genitourinary cancers undergoing CT during an ER visit at a tertiary cancer center during a 20-month period. CTs were considered positive if there were findings relevant to the presenting complaint(s). Demographic/clinical variables were recorded. OS was evaluated using Kaplan-Meier curves. Univariate and multivariate Cox proportional hazards regression (HR) was used to evaluate OS predictors.

RESULTS

Two hundred twenty-seven patients (243 visits) were included. The most common primary tumors were prostate (121 [49.8%]), bladder/urothelial (78 [32.1%]), and renal (69 [28.4%]). Common presenting complaints were abdominal pain (67 [27.6%]), respiratory symptoms (49 [20.2%]), neurological signs (37 [15.2%]), and fever (34 [14.0%]). CT findings were positive in 172 patients (70.8%) and included new/increased metastases (21.4% [52/243]), fluid collections (7.4% [18/243]), urinary tract infection/inflammation (6.2% [15/243]), enteritis/colitis (5.3% [13/243]), and pneumonia (4.9% [12/243]). A positive ER CT was associated with patient admission (p = 0.01). At multivariate analysis, independently predictive factors of shorter survival were positive ER CT (HR = 2.09 [95% CI 1.16-3.76, p = 0.01), hospital admission (HR = 2.17 [95% CI 1.38-3.41], p < 0.01), and recent systemic treatment (HR = 2.10 [95% CI 1.32-3.35], p < 0.01).

CONCLUSION

When CT was performed, it was able to identify a structural cause for the presenting complaint in the majority of patients with genitourinary cancers attending the ER. A positive ER CT was associated with hospital admission and poorer overall survival.

Racial differences in testicular cancer in the United States: descriptive epidemiology

BACKGROUND

Testicular cancer (TC) is the most common malignancy in young adult men, and in many countries the incidence rates of testicular cancer have been increasing since the middle of the twentieth century. Since disease presentation and tumor progression patterns are often heterogeneous across racial groups, there may be important racial differences in recent TC trends.

METHODS

In this study, Surveillance, Epidemiology, and End Results (SEER) data on TC patients diagnosed between 1973 and 2015 were analyzed, including the following racial/ethnic groups: non-Hispanic whites (NHW), Hispanic whites (HW), blacks, and Asians and Pacific Islanders (API). Patient characteristics, age-adjusted incidence rates, and survival were compared across racial groups. A multivariate Cox model was used to analyze the survival data of TC patients, in order to evaluate racial differences across several relevant factors, including marital status, age group, histologic type, treatment, stage, and tumor location.

RESULTS

NHWs had the highest incidence rates, followed by blacks, HWs, and APIs. There were significant survival differences among the racial groups, with NHWs having the highest survival rates and blacks having the lowest.

CONCLUSION

An analysis of SEER data showed that racial differences existed among TC patients in the United States with respect to patient characteristics, incidence, and survival. The results can be useful to stakeholders interested in reducing the burden of TC morbidity and mortality.

Trends in incidence, mortality and survival of testicular cancer patients in Belarus

INTRODUCTION

The objective of this study was to assess recent trends in incidence, mortality and relative survival (RS) in testicular cancer (TC) patients in Belarus and to provide international comparisons of our figures.

MATERIAL AND METHODS

We surveyed the Belarusian Cancer Registry for all male cases diagnosed with International Classification of Diseases for Oncology, third edition (ICD-O-3) topography code C62 between 1990 and 2015. Trends for incidence and mortality rates per 100,000 of the world standard population and annual percentage changes (APCs) were calculated. We also estimated the 1- and 5-year RS rates for the 1990-1998, 1999-2007 and 2008-2015 periods according to the Ederer II method. The RS estimates for the 2008-2015 period were age-standardized and compared with the published EUROCARE-5 data and SEER-18 database analysis.

RESULTS

A total of 2,500 and 2,439 cases were included into incidence and survival analyses, respectively. We found a significant increase in the TC age-standardized incidence rate (APC 2.6%) and a decline in the age-standardized mortality (APC -3.0%) over the study period. RS significantly increased in all patients` strata; a relative increase was more pronounced in advanced stages of seminoma and younger age groups. Nevertheless, the most recent figures of age-standardized RS including stage-specific estimates were generally worse than the European and SEER data.

CONCLUSIONS

We have found a significant increase in TC incidence in Belarus in recent years. Mortality has significantly declined with a corresponding increase in RS which, however, did not reach European or North American figures. Continued effort is required to improve the quality of management of TC patients in our country.

Correlations between Mortality-to-Incidence Ratios and Health Care Disparities in Testicular Cancer

The mortality-to-incidence ratio (MIR) is associated with the clinical outcomes of different types of cancer as well as the ranking of health care systems. However, the association between MIRs for testicular cancer and health care disparities, including differences in expenditures and health system rankings, has not yet been reported. We used the Spearman’s rank correlation coefficient (CC) to analyze the correlation between testicular cancer MIRs and both total expenditures on health/gross domestic product (e/GDP) and the World Health Organization’s (WHO) health system rankings. After screening the data for quality and missing information, 57 countries were chosen for analysis. Generally, developed countries and regions had relatively high rates of incidence/mortality, but with a favorable MIR. Among the continents, Europe had the highest incidence rates, whereas the highest MIRs were in Africa. Globally, favorable testicular cancer MIRs were observed in countries with both a high e/GDP and a good WHO ranking (R² = 0.325, p < 0.001 and CC = −0.568, p < 0.001; R² = 0.367, p < 0.001 and CC = 0.655, p < 0.001, respectively). In conclusion, the MIR for testicular cancer varies in countries and regions based on both their total health expenditure and their health care system ranking.

The impact of age at orchiopexy on testicular cancer outcomes

PURPOSE

To estimate how many boys with UDT must undergo orchiopexy to prevent one case of TC, one death from TC and one exposure to TC treatment beyond radical orchiectomy as compared to being treated at an older age.

METHODS

This retrospective study utilized data from a 2007 Swedish study of males who underwent orchiopexy for UDT (Pettersson et al.). TC incidence for boys undergoing orchiopexy for UDT was assessed based on the age at orchiopexy (0-6 years, 7-9 years, 10-12 years, 13-15 years). The incidence of TC in each age cohort was calculated and used to determine the number needed to treat (NNT) for each age group using assumptions based on published TC outcomes.

RESULTS

For an index patient ≤ 6 years, 372 boys need to undergo orchiopexy to prevent a single case of TC, 1488 boys to prevent exposure to TC therapy beyond radical orchiectomy, and 5315 boys to prevent a single TC-related death compared to treatment at an older age.

CONCLUSION

While there is evidence supporting benefits of early orchiopexy, the NNT to affect TC outcomes is very high. Even those with delayed orchiopexies have low risk for TC poor outcomes. This information can be used when counseling patients and families faced with UDT about the risks related to TC, especially with comorbidities.

Testicular Cancer Incidence and Mortality Within Rural and Urban Regions

Purpose: Testicular cancer (TCa) is among the most common cancers within adolescent and young adult (AYA) male populations. However, information is limited to variations in incidence and mortality outside of racial/ethnic subgroups. Rural regions historically have a greater overall cancer incidence than urban regions, although some key differences exist regarding site. TCa-specific incidence and mortality disparities are not commonly reported in this context. This study aims to help fill that gap by providing discovery evidence if there is an association between US rural/urban regions and TCa incidence and mortality. Methods: Secondary analysis of Surveillance, Epidemiology, and End Results incidence and mortality data were employed to determine if rural/urban TCa incidence and mortality disparities exist among U.S. males. Results: There was a 2.6% increased rate of TCa in U.S. urban as compared with rural geographic regions from 2011 to 2015. When geographic region is disaggregated, rural regions see higher rates than urban. When factoring in race/ethnicity, White/Caucasians and Hispanics had statistically higher urban rates whereas American Indian/Alaskan Natives and Asian/Pacific Islander groups had statistically higher rural rates. Conclusion: Geographic regional TCa variation research is virtually nonexistent for U.S. males, specifically AYAs of color. Determining preliminary trends in rural and urban regions can assist in the creation of more targeted services, particularly among underserved and vulnerable populations that have tenuous access to health care, to reduce disparate health outcomes. Exploring geographic differences in TCa incidence and mortality can have implications within service industry, health care accessibility, and public health justice areas of research and outreach.

Temporal trends in management and outcomes of testicular cancer: A population-based study

BACKGROUND

Treatment guidelines for early-stage testicular cancer have increasingly recommended de-escalation of therapy with surveillance strategies. This study was designed to describe temporal trends in routine clinical practice and to determine whether de-escalation of therapy is associated with inferior survival in the general population.

METHODS

The Ontario Cancer Registry was linked to electronic records of treatment to identify all patients diagnosed with testicular cancer treated with orchiectomy in Ontario during 2000-2010. Treatment after orchiectomy was classified as radiotherapy (RT), retroperitoneal lymph node dissection (RPLND), chemotherapy, or none. Surveillance was defined as no identified treatment within 90 days of orchiectomy. Overall survival (OS) and cancer-specific survival (CSS) were measured from the date of orchiectomy.

RESULTS

The study population included 1564 and 1086 cases of seminomas and nonseminoma germ cell tumors (NSGCTs), respectively. Among patients with seminomas, there was a significant increase in the proportion of patients with no treatment within 90 days of orchiectomy (from 56% to 84%; P < .001); the use of RT decreased over time (from 38% to 8%; P < .001); and the use of chemotherapy remained stable (from 6% to 9%; P = .289). Practice patterns 90 days after orchiectomy remained stable over time among patients with NSGCTs: from 51% to 57% for no treatment (P = .435), from 43% to 43% for chemotherapy (P = .336), and from 9% to 3% for RPLND (P = .476). The OS rates for the entire cohort at 5 and 10 years were 97% and 96%, respectively; the CSS rates were 98% and 98%, respectively. There was no significant change in OS or CSS for patients with seminomas or NSGCTs during the study period.

CONCLUSIONS

There has been substantial de-escalation in the treatment of testicular cancer in routine practice since 2000. Long-term survival in routine practice is excellent and has not decreased with the uptake of surveillance strategies. Cancer 2018;124:2724-2732. © 2018 American Cancer Society.

Incorporating age into International Germ Cell Consensus Classification (IGCCC): a time to move forward?

BACKGROUND

Older age is a poor prognostic indicator among patients with germ cell tumors. The current study evaluates an age-integrated international germ cell consensus classification (IGCCC) for advanced germ cell tumors.

METHODS

SEER database (2004-2014) was accessed through SEER*Stat program and both IGCCC and age-integrated IGCCC were calculated based on site of the primary, site of the metastasis and level of tumor markers. Overall survival analyses according to IGCCC and age-integrated IGCCC were conducted through Kaplan-Meier analysis.

RESULTS

Overall survival was compared according to IGCCC and age-integrated IGCCC for patients with seminoma and Non-seminomatous germ cell tumors (NSGCTs). P values were significant (P <0.001) for all scenarios. c-index for seminoma for IGCCC was 0.553; c-index for seminoma for age-integrated IGCCC was 0.664;c-index for NSGCTs for IGCCC was 0.729; and c-index for NSGCTs for age-integrated IGCCC was 0.738. A Cox-regression multivariate model of factors affecting cancer-specific survival (adjusted for race and surgical treatment) was conducted. All P values for pair wise comparisons (among different age-integrated IGCCC categories) were significant for both seminoma and NSGCTs (P<0.01).

CONCLUSION

Compared to traditional IGCCC, age-integrated IGCCC is more discriminatory and the new risk groups introduced within it are prognostically relevant.

Will Testicular Germ Cell Tumors Remain Untargetable?

Testicular Germ cell tumors (TGCT) represent the most common solid tumors affecting young men. They constitute a distinct entity because of their embryonic origin and their unique biological behavior. Recently, new preclinical data on genetic and epigenetic susceptibility profiles, biological signaling machinery as well as on molecular patterns of tumors and pathways of pathogenesis helped to elucidate the pathogenesis and the differentiation of TGCTs and to understand the mechanisms behind the development of resistance to treatment. In the present work, we have reviewed new clues to the development, differentiation and progression of TGCTs. We focus on the most important epigenetic and molecular biomarkers, and discussed their diagnostic and prognostic accuracy compared to the currently used biomarkers. The mechanisms underlying the development of resistance to cisplatin and commonly used chemotherapeutic agents are also discussed in detail. Finally, we summarize failed and ongoing clinical trials using targeted therapies in resistant TGCTs, and analyze the potential of new targeted therapies.

Reimbursements and frequency of tests in privately insured testicular cancer patients in the United States: Implications to national guidelines

Objectives:

The objective of this study was to assess the frequency of utilization and reimbursement of the common diagnostic tests and treatment modalities used in testicular cancer care.

Methods:

LifeLink™ (IMS Health, Danbury, CT, USA) Claims Database was used. We identified 877 subjects with a primary diagnosis of testicular cancer (ICD 186.9) between 2007 and 2012. Median reimbursement and frequency of the diagnostic/treatment modalities used were recorded.

Results:

The most common claim was a vein puncture with median reimbursement of $9.11. Tumor markers, alpha-fetoprotein and beta human chorionic gonadotropin, were ranked 6^th and 7^th with median reimbursement of $52.13 and $48.71, respectively. Chest X-ray and computerized tomography (CT) scan of the chest were ranked 9^th and 13^th with median reimbursement of $68.51 and $769, respectively. A contrast CT scan of abdomen and pelvis was the 11^th most frequent claim with median reimbursement of $855.89. The three invasive treatment modalities, chemotherapy, radiation therapy, and retroperitoneal lymphadenectomy were ranked 8^th, 15^th, and 164^th with median reimbursement of $2858.38, $3988.25, and $2009.67, respectively.

Conclusions:

Testicular cancer is not an inexpensive disease. Surgery is the less utilized than radiation and chemotherapy despite lower cost. This may have implications to national guidelines and training since these treatments often carry the same grade of recommendation.

Testicular germ cell tumor: Short and long-term side effects of treatment among survivors

Long-term prognosis of germ cell tumor (GCT) types is excellent, however, treatment is associated with non-negligible complication rates and a negative impact on quality of life. The present study described treatment results in terms of survival, both short and long-term toxicity, and paternity rates in a cohort of patients treated at Jules Bordet Institute, University ULB of Brussels (Brussels, Belgium). The present study analyzed the data of a cohort of patients with GCT types. Pre-operative patient and tumor characteristics were described. Performance status, pulmonary function tests and renal clearance prior to chemotherapy were noted. Chemotherapeutic regimens and their associated toxicities were analyzed. The duration to event-free, cancer-specific and overall survivals were estimated using Kaplan-Meier curves. A total of 115 patients (median age, 31-years-old) were treated for a GCT at Jules Bordet Institute. At a median follow-up of 6-years, 11 (10%) patients had relapsed and 2 (2%) developed a second malignant neoplasm. At the final follow-up, 97 (89%) and 6 (5.5%) patients exhibited complete and partial remission, respectively. A total of 6% of patients exhibited a progressive disease. In terms of short-term toxicity, 11% of patients presented with febrile neutropenia. The 10-year overall survival rate and relapse-free survival rate were 93.4 and 89.8%, respectively. The paternity rate post-treatment was 27%. Testicular GCT survivors suffered from short- and long-term treatment-associated side effects on both a physical and psychological level. A long-term close follow-up is necessary in order to assist the patient with these treatment-induced complications.