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Article of the week: Global, regional and national burden of testicular cancer, 1990–2016: results from the Global Burden of Disease Study 2016

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community, and a video prepared by the authors. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

Global, regional and national burden of testicular cancer, 1990–2016: results from the Global Burden of Disease Study 2016

Farhad Pishgar*, Arvin Haj-Mirzaian, Hedyeh Ebrahimi*, Sahar Saeedi Moghaddam*, Bahram Mohajer*, Mohammad Reza Nowroozi, Mohsen Ayati,  Farshad Farzadfar*, Christina Fitzmaurice§¶ and Erfan Amini

*Non-Communicable Diseases Research Centre, Endocrinology and Metabolism Population Sciences Institute, Uro-Oncology Research Centre, Endocrinology and Metabolism Research Centre, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran, §Institute for Health Metrics and Evaluation, andDivision of Haematology, Department of Medicine, University of Washington, Seattle, WA, USA

Abstract

Objective

To provide estimates of the global incidence, mortality and disability‐adjusted life‐years (DALYs) associated with testicular cancer (TCa) between 1990 and 2016, using findings from the Global Burden of Disease (GBD) 2016 study.

Materials and Methods

For the GBD 2016 study, cancer registry data and a vital registration system were used to estimate TCa mortality. Mortality to incidence ratios were used to transform mortality estimates to incidence, and to estimate survival, which was then used to estimate 10‐year prevalence. Prevalence was weighted using disability weights to estimate years lived with disability (YLDs). Age‐specific mortality and a reference life expectancy were used to estimate years of life lost (YLLs). DALYs are the sum of YLDs and YLLs.

Fig.1. Testicular cancer incidence, mortality and DALYs globally, and in the five socio‐demographic index (SDI) quintiles. (A) Incident cases. (B) Age‐standardized incidence rate (ASIR). (C) Deaths. (D) ASDR. (E) Disability‐adjusted life‐year (DALYs). (F) Age‐standardized DALY rate.

Results

Global incidence of TCa showed a 1.80‐fold increase from 37 231 (95% uncertainty interval [ UI] 36 116–38 515) in 1990 to 66 833 (95% UI 64 487–69 736) new cases in 2016. The age‐standardized incidence rate also increased from 1.5 (95% UI 1.45–1.55) to 1.75 (95% UI 1.69–1.83) cases per 100 000. Deaths from TCa remained stable between 1990 and 2016 [1990: 8394 (95% UI 7980–8904), 2016: 8651 (95% UI 8292–9027)]. The TCa age‐standardized death rate decreased between 1990 and 2016, from 0.39 (95% UI 0.37–0.41) to 0.25 (95% UI 0.24–0.26) per 100 000; however, the decreasing trend was not similar in all regions. Global TCa DALYs decreased by 2% and reached 391 816 (95% UI 372 360–412 031) DALYs in 2016. The age‐standardized DALY rate also decreased globally between 1990 and 2016 (10.31 [95% UI 9.82–10.84]) per 100 000 in 2016).

Conclusion

Although the mortality rate for TCa has decreased over recent decades, large disparities still exist in TCa mortality, probably as a result of lack of access to healthcare and oncological treatment. Timely diagnosis of this cancer, by improving general awareness, should be prioritized. In addition, improving access to effective therapies and trained healthcare workforces in developing and under‐developed areas could be the next milestones.

Editorial: Testicular cancer outcome inequality: a curable disease?

Inequalities in cancer survival exist across cities, countries and global regions [1]. Testicular cancer provides a particularly stark example. It has extremely high survival rates, but cure is strongly dependent upon prompt diagnosis. In turn, that depends on reliable access to high‐quality healthcare [23].

In this issue of BJUI, Pishgar et al. [4] report a richly detailed analysis of international variations in testicular cancer mortality. Using data from the 2016 Global Burden of Disease study (GBD), they examine variation in incidence and outcomes from testicular cancer, including impact on disability‐adjusted life years (DALYs) and mortality, across 21 regions and 195 countries, since the GBD started in 1990.

Testicular cancer incidence increased globally between 1990 and 2016. This may reflect underlying, environmentally determined birth cohort effects, improving identification of underlying disease burden, or both [5]. Notably, increases do not appear to have been shared evenly between countries, or across different social sociodemographic index (SDI) quintiles; the age‐standardised incidence rate actually decreased in the low and low–middle SDI quintiles, but increased in high, high–middle and middle SDI quintiles. However, evidence of a link between access to healthcare and incidence of testicular cancer is lacking.

More strikingly, the authors conclude that although testicular cancer survival globally is improving, disparities between countries remain entrenched. In fact, a countervailing increase in mortality in some developing countries over the study period suggests a major task ahead for those healthcare systems.

Testicular cancer does not have a screening test. Early diagnosis and optimal outcome generally relies upon self‐examination; prompt referral to a urology service for initial surgical management; and early involvement of a wider multidisciplinary team, including a specialist oncologist; in accordance with international guidelines. Accordingly, disparities in testicular cancer outcomes may be attributable to variations in one or more of the following:

  • Education and health literacy
  • Health insurance cover, equivalent ability to pay ‘out of pocket’ (OOP) charges. With the health insurance coverage, cover your family to protect them from costly final expenses by getting a final expense insurance or burial insurance from insuranceforfinalexpense.com.
  • Access to both primary care and specialty services
  • Availability of key resources (e.g., platinum‐based chemotherapy)
  • Adherence to best practice guidelines

Access to healthcare and protection of individuals from OOP costs may predominate amongst all of these factors. In countries with partial or total OOP funding, the early diagnosis of cancer risks being seen, not as an opportunity to avert the development of life‐threatening disease, but as a financial decision with significant personal and family implications [6]. Encouraging proactive health‐seeking behaviours is challenging in the setting of universal health coverage; much more so in the context of such basic conflicts. The likely effects of these conflicts are observable in developed and developing countries alike, as long as OOP costs remain a fact of life for significant numbers of citizens [23].

The Pishgar et al. [4] study, and the GBD more widely, are subject to some basic methodological limitations inherent in any international registry‐based analysis. Unmeasured and uncontrolled confounding is inevitable. Variation in outcomes between countries and over time may reflect true variation, or variation in coding practice, quality assurance and accuracy.

More fundamentally, quantitative analysis is limited to identifying, rather than explaining international trends in cancer outcomes. Such trends can then be used to generate hypotheses. Qualitative methods can then be incorporated, generating meaningful insights into different healthcare systems’ relative performances, and testing those hypotheses.

Building on the data reported here, Medicare Advantage 2020 qualitative analysis incorporate insights into better‐performing countries’ strategies for promoting self‐examination, and providing high‐quality, evidence‐based multidisciplinary care, through an appropriately trained specialist workforce, could provide a basis for developing countries to develop their own contextually tailored strategies. Across many developing world contexts, access to platinum‐based chemotherapy remains an essential priority [7].

It is notable that DALYs are incorporated into this high‐level international comparison and encouraging that they are falling globally [4]. Again, combining qualitative analysis with the insights provided by these international and temporal analyses of DALYs could enrich our understanding of the interaction between approaches to testicular cancer care and patient experience. For example, Pishgar et al. [4] report that Kiribati, Chile, and Argentina had the highest testicular cancer‐specific age‐standardised DALY rates. Focussed qualitative research in these countries, possibly incorporating comparisons with higher performing settings, could facilitate targeted improvements to patient care and experience. As more countries achieve the highest cure rates for testicular cancer, patient experience will assume increasing importance as a measure of care quality in this disease.

Analyses like this have the potential to provoke important conversations and to generate hypotheses in specialist clinical and health policy research. As clinicians, researchers and policy‐makers, this study should encourage us to think critically about the policy context in which we see testicular cancer, the reasons patients might present late, and how equity of outcome might be achieved both within and beyond our own immediate surroundings. Pishgar et al. [4] invaluably remind us that we remain some way off being able to call testicular cancer a curable disease for all patients, in all settings.

References

  1. Global Cancer Observatory (GLOBOCAN). Available at: https://gco.iarc.fr. Accessed June 2019.
  2. Markt SCLago‐Hernandez CAMiller RE et al. Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors. Cancer 20161223127– 35
  3. Withington JCole AP, Meyer CP et alComparison of testis cancer‐specific survival: an analysis of national cancer registry data from the USA, UK and Germany. BJU Int 2019123385– 7
  4. Pishgar FHaj‐Mirzaian AEbrahimi H et al. Global, regional, and national burden of testicular cancer, 1990–2016: results from the global burden of disease study 2016. BJU Int 2019124386– 94
  5. Shanmugalingam TSoultati AChowdhury S, Rudman S, Van Hemelrijck M. Global incidence and outcome of testicular cancer. Clin Epidemiol 20135417– 27
  6. Rajpal SKumar AJoe WEconomic burden of cancer in India: evidence from cross‐sectional nationally representative household survey, 2014. PLoS One 201813e0193320.
  7. Lancet Global Health. Lifting the veil on cancer treatment. Lancet 2019; 7: PE281. DOI: 10.1016/ S2214‐109X(19)30014‐2

Article of the week: Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, it should be this one.

Examining the relationship between complications and perioperative mortality following radical cystectomy: a population‐based analysis

Matthew Mossanen*†‡, Ross E. Krasnow§, Dimitar V. Zlatev*, Wei Shen Tan**, Mark A. Preston*, Quoc-Dien Trinh*†‡, Adam S. Kibel*, Guru Sonpavde, Deborah Schrag, Benjamin I. Chung†† and Steven L. Chang*†††

*Division of Urology, Harvard Medical School, Brigham and Womens Hospital, Lank Center for Genitourinary Oncology, Dana-Farber Cancer Institute, Center for Surgery and Public Health, Brigham and Womens Hospital, Boston, MA, Division of Surgery and Interventional Sciences, Department of Urology, University College London, **Department of Urology, Imperial College Healthcare, London, UK, §Department of Urology, Georgetown University, Washington, DC, USA and ††Department of Urology, Stanford University Medical Center, Stanford, CA, USA
Read the full article

Abstract

Objective

To examine the incidence of perioperative complications after radical cystectomy (RC) and assess their impact on 90‐day postoperative mortality during the index stay and upon readmission.

Patients and methods

A total of 57 553 patients with bladder cancer (unweighted cohort: 9137 patients) treated with RC, at 360 hospitals in the USA between 2005 and 2013 within the Premier Healthcare Database, were used for analysis. The 90‐day perioperative mortality was the primary outcome. Multivariable regression was used to predict the probability of mortality; models were adjusted for patient, hospital, and surgical characteristics.

Results

An increase in the number of complications resulted in an increasing predicted probability of mortality, with a precipitous increase if patients had four or more complications compared to one complication during hospitalisation following RC (index stay; 1.0–9.7%, P < 0.001) and during readmission (2.0–13.1%, < 0.001). A readmission complication nearly doubled the predicted probability of postoperative mortality as compared to an initial complication (3.9% vs 7.4%, P < 0.001). During the initial hospitalisation cardiac‐ (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.9–5.1), pulmonary‐ (OR 4.8, 95% CI 2.8–8.4), and renal‐related (OR 3.6, 95% CI 2–6.7) complications had the most significant impact on the odds of mortality across categories examined.

Conclusions

The number and nature of complications have a distinct impact on mortality after RC. As complications increase there is an associated increase in perioperative mortality.

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Article of the month: Prostate cancer mortality rates in Peru and its geographical regions

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

Prostate cancer mortality rates in Peru and its geographical regions

Junior Smith Torres-Roman*, Eloy F. Ruiz, Jose Fabian Martinez-Herrera§, Sonia Faria Mendes Braga, Luis Taxa**, Jorge Saldaña-Gallo*, Mariela R. Pow-Sang††, Julio M. Pow-Sang‡‡ and Carlo La Vecchia§§

 

*Clinica de Urologia Avanzada UROZEN, Lima, Facultad de Medicina Humana, Universidad Nacional San Luis Gonzaga, Ica, CONEVID, Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru, §Cancer Center, Medical Center American British Cowdray, Mexico City, Mexico, Department of Social and Preventive Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil, **Instituto Nacional de Enfermedades Neoplásicas, ††Department of Urology, Instituto Nacional de Enfermedades Neoplásicas, Lima, Peru, ‡‡Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA, and §§Department of Clinical Sciences and Community Health, Universitá degli Studi di Milano, Milan, Italy

 

Read the full article

Abstract

Objective

To evaluate the mortality rates for prostate cancer according to geographical areas in Peru between 2005 and 2014.

Materials and Methods

Information was extracted from the Deceased Registry of the Peruvian Ministry of Health. We analysed age‐standardised mortality rates (world population) per 100 000 men. Spatial autocorrelation was determined according to the Moran Index. In addition, we used Cluster Map to explore relations between regions.

Fig. 1. Peru geographical zones by provinces. The asterisk denotes the province of Callao. Source: National Statistics Institute

Results

Mortality rates increased from 20.9 (2005–2009) to 24.1 (2010–2014) per 100 000 men, an increase of 15.2%. According to regions, during the period 2010–2014, the coast had the highest mortality rate (28.9 per 100 000), whilst the rainforest had the lowest (7.43 per 100 000). In addition, there was an increase in mortality in the coast and a decline in the rainforest over the period 2005–2014. The provinces with the highest mortality were Piura, Lambayeque, La Libertad, Callao, Lima, Ica, and Arequipa. Moreover, these provinces (except Arequipa) showed increasing trends during the years under study. The provinces with the lowest observed prostate cancer mortality rates were Loreto, Ucayali, and Madre de Dios. This study showed positive spatial autocorrelation (Moran’s I: 0.30, P= 0.01).

Conclusion

Mortality rates from prostate cancer in Peru continue to increase. These rates are higher in the coastal region compared to those in the highlands or rainforest.

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Editorial: The burden of urological cancers in low‐ and middle‐income countries

The burden of cancer in low‐ and middle‐income countries (LMICs) continues to rise [1]. Evaluation of geographical differences in cancer mortality statistics is specifically of interest in LMICs as (inter)national guidelines are potentially less embedded in standard care, and objective measurements to assess underlying mechanisms/explanations for the burden of cancer are often lacking. Monitoring mortality statistics in these countries can thus help assess the effectiveness of national and regional health systems in treating and caring for patients with cancer [1].

Torres‐Roman et al. [2] deserve to be congratulated for their efforts to monitor mortality rates for prostate cancer at both a regional and national level in Peru. The CONCORD initiative from the WHO previously reported prostate cancer statistics for Peru, but data were limited to the capital area of Lima [1]. Torres‐Raman et al. [2] report prostate cancer mortality rates between 2005 and 2014 based on data from the Peruvian Ministry of Health, which covers ~70% of all healthcare providers in Peru. Apart from an overall increase of 15% in mortality rates, substantial variation was observed by geographical region. Mortality rates increased by 16% in the coastal region and highlands, whereas in the rainforest region the rates decreased by 19% [2]. One potential explanation for these observed differences could be the difference in ethnic and racial characteristics. The coastal region in Peru has a strong African influence and also has a larger proportion of men aged >65 years. In addition to potential differences in access to healthcare, some of the variation in prostate cancer mortality statistics most likely reflects a deficiency in reporting systems. Even though this study has its limitations due to missing data and lack of information on other important variables, such as ethnicity and socioeconomic status, it provides a first base for a critical assessment of prostate cancer care in Peru.

Studies like this one from Torres‐Roman et al. [2] show that there is a need for improvement and standardisation of (prostate) cancer care in LMICs, but also a need for improvement in data capturing, so that objective measurements can be put in place. The years of healthy life lost due to prostate cancer, as well as other urological cancers, in LMICs is increasing substantially. Even though each tumour group has its own specifications in terms of prevention and control, an epidemiological assessment of cancer burden based on the experience for urological cancers (i.e., prostate, bladder, kidney and testicular) can therefore inform future assessments of cancer burden. The urological tumour group covers both common and less common cancers (e.g. prostate vs kidney cancer), sex‐specific and cancers that affect both sexes (e.g. testicular vs bladder cancer), cancers with less known risk factors and those strongly linked with lifestyle risk factors (e.g. prostate vs bladder cancer).

It is encouraging to see an increase in the number of studies evaluating the burden of cancer in LMICs [3]; however, given the consistency in observations of an increase in mortality, there is an urgent need to further invest in prevention and management, as well as the infrastructure to collect all relevant data at a national level in these LMICs. Accurate information about cancer burden and how this varies between regions is essential to plan for an adequate health‐system response.

References

  1. Allemani, CMatsuda, TCarlo, V et al. Global surveillance of trends in cancer survival 2000‐14 (CONCORD‐3): analysis of individual records for 37 513 025 patients diagnosed with one of 18 cancers from 322 population‐based registries in 71 countries. Lancet 20183911023– 75
  2. Torres‐Roman, JRuiz, EMartinez‐Herrera, J et al. Prostate cancer mortality rates in Peru and its geographic regions. BJU Int 2019123595– 601
  3. Carioli, GVecchia, CBertuccio, P et al. Cancer mortality predictions for 2017 in Latin America. Ann Oncol 2017282286– 97

 

Article of the month: Mortality after radical prostatectomy in a matched contemporary cohort in Sweden compared to the Scandinavian Prostate Cancer Group 4 study

Every month, the Editor-in-Chief selects an Article of the Month from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial written by a prominent member of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this week, it should be this one.

 

Mortality after radical prostatectomy in a matched contemporary cohort in Sweden compared to the Scandinavian Prostate Cancer Group 4 (SPCG‐4) study

Walter Cazzaniga*†‡, Hans Garmo§¶, David Robinson**, Lars Holmberg, Anna Bill-Axelson and Pär Stattin
 
 
*Division of Experimental Oncology/Unit of Urology URI, IRCCS Ospedale San Raffaele, University Vita-Salute San Raffaele, Milan, Italy, Department of Surgical Sciences, Uppsala University, §Regional Cancer Centre Uppsala Örebro, Uppsala University Hospital, Uppsala, Sweden, Division of Cancer Studies, Cancer Epidemiology Group, King’s College London, London, UK, and **Department of Urology, Ryhov Hospital, Jönköping, Sweden
 

 

Read the full article

Abstract

Objectives

To investigate if results in terms of absolute risk in mature randomised trials are relevant for contemporary decision‐making. To do so, we compared the outcome for men in the radical prostatectomy (RP) arm of the Scandinavian Prostate Cancer Group Study number 4 (SPCG‐4) randomised trial with matched men treated in a contemporary era before and after compensation for the grade migration and grade inflation that have occurred since the 1980s.

Patients and Methods

A propensity score‐matched analysis of prostate cancer mortality and all‐cause mortality in the SPCG‐4 and matched men in the National Prostate Cancer Register (NPCR) of Sweden treated in 1998–2006 was conducted. Cumulative incidence of prostate cancer mortality and all‐cause mortality was calculated. Cox proportional hazards regression analyses were used to estimate hazard ratios (HR) and 95% confidence intervals (CIs) for a matching on original Gleason Grade Groups (GGG) and second, matching with GGG increased one unit for men in the NPCR.

 
Figure 1: Cumulative incidence of prostate cancer mortality (PCM) and all‐cause mortality (ACM) in the SPCG‐4 and the NPCR of Sweden. FU, follow‐up after date of diagnosis or primary treatment. A and B based on original GGG. C and D based on upgraded GGG classification in the NPCR with an increase of one grade in GGG.

Results

Matched men in the NPCR treated in 2005–2006 had half the risk of prostate cancer mortality compared to men in the SPCG‐4 (HR 0.46, 95% CI 0.19–1.14). In analysis of men matched on an upgraded GGG in the NPCR, this difference was mitigated (HR 0.73, 95% CI 0.36–1.47).

Conclusion

Outcomes after RP for men in the SPCG‐4 cannot be directly applied to men in the current era, mainly due to grade inflation and grade migration. However, by compensating for changes in grading, similar outcomes after RP were seen in the SPCG‐4 and NPCR. In order to compare historical trials with current treatments, data on temporal changes in detection, diagnostics, and treatment have to be accounted for.

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