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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

Video: Global, regional and national burden of testicular cancer

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

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.

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.

by @ErfanAmini and @FarhadPishgar

 

#RudeFood: Foodporn for a purpose

The Internet is full of weird and wonderful things. Of course, we all know what is most frequently viewed and shared online. That’s right – food! Nonetheless, when celebrity chef Manu Fieldel posted a photo of his latest creation, it certainly made people look long and hard!


Soon it became clear that this naughty creation had a noble purpose – supporting a campaign to raise awareness of the so-called #BelowTheBelt cancers. While most people may have heard of prostate and bladder cancers, being relatively common, other #BelowTheBelt cancers such as penile and testicular cancers are rarer and relatively unknown. To make matters worse, these cancers affect men either exclusively or predominantly – and we all know how reluctant men can be to go to the doctors.

Hence, the #RudeFood campaign was developed by the Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group. ANZUP is the peak co-operative trials group for #BelowTheBelt cancers in Australia and New Zealand. ANZUP has and continues to develop and run many significant clinical trials, including the Enzamet and Enzarad trials for prostate cancer, the Phase III accelerated BEP trial for germ-cell tumours, the sequential BCG-mitomycin trial for bladder cancer and the Eversun and Unison trials in kidney cancer.

The week started with things heating up at ANZUP as they brought #RudeFood to the unsuspecting world!

Manu’s phallic creation was also matched by Ainsley Harriot, Sonia Meffadi and Monty Kulodrovic.

To counterpoint the raunch, there were also poignant personal connections from Simon Leong and Scott Gooding who both described family members who had suffered from prostate cancer.


Over the week, #RudeFood has certainly drawn some attention, including from media outlets such as Mamamia, news.com.au and GOAT. 

A poetic contribution on #RudeFood caught the eye of @UroPoet across the seas. Let us hope this campaign will also lead to greater awareness of #BelowTheBelt cancers and improved outcomes for those affected by them.


Shomik Sengupta is Professor of Surgery at the EHCS of Monash University and visiting urologist & Uro-Oncology lead at Eastern Health. Shomik has particular interests in prostate cancer, including open and robotic prostatectomy, as well as bladder cancer, including cystectomy with neobladder diversion. Shomik is the current leader of the UroOncology SAG within USANZ, and the past chair of Victorian urology training.  Shomik is a Board member and scientific advisory member of the ANZUP Cancer trials group and is heavily involved in numerous clinical trials in GU oncology.

Twitter: @shomik_s 


Article of the Week: Occupational variation in the incidence of testicular cancer in the Nordic countries

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 accompanying editorial written by a prominent member of the urological community. This blog is 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.

Time trends and occupational variation in the incidence of testicular cancer in the Nordic countries

Outi Ylönen*, Sirkku Jyrkkiö, Eero Pukkala§, Kari Syvanen and Peter J. Bostrom

*South-Karelian Central Hospital, University Hospital of Turku, Lappeenranta, Finland, Department of Oncology, ¶Department of Urology, University Hospital of Turku, Turku, Finland, School of Health Sciences, University of Tampere, Tampere, Finland and §Finnish Cancer Registry, Helsinki, Finland

 

Abstract

Objective

To describe the trends and occupational variation in the incidence of testicular cancer in the Nordic countries utilising national cancer registries, NORDCAN (NORDCAN project/database presents the incidence, mortality, prevalence and survival from >50 cancers in the Nordic countries) and NOCCA (Nordic Occupational Cancer) databases.

Patients and Methods

We obtained the incidence data of testicular cancer for 5‐year periods from 1960–1964 to 2000–2014 and for 5‐year age‐groups from the NORDCAN database. Morphological data on incident cases of seminoma and non‐seminoma were obtained from national cancer registries. Age‐standardised incidence rates (ASR) were calculated per 100 000 person‐years (World Standard). Regression analysis was used to evaluate the annual change in the incidence of testicular cancer in each of the Nordic countries. The risk of testicular cancer in different professions was described based on NOCCA information and expressed as standardised incidence ratios (SIRs)

Fig. 2. Testicular cancer incidence time trends by age in the Nordic countries 1960-2014 (5-year floating averages).

Results

During 2010–2014 the ASR for testicular cancer varied from 11.3 in Norway to 5.8 in Finland. Until 1998, the incidence was highest in Denmark. There has not been an increase in Denmark and Iceland since the 1990s, whilst the incidence is still strongly increasing in Norway, Sweden, and Finland. There were no remarkable changes in the ratio of seminoma and non‐seminoma incidences during the past 50 years. There was no increase in the incidences in children and those of pension age. The highest significant excess risks of testicular seminoma were found in physicians (SIR 1.48, 95% confidence interval [CI] 1.07–1.99), artistic workers (SIR 1.47, 95% CI 1.06–1.99) and religious workers etc. (SIR 1.33, 95% CI 1.14–1.56). The lowest SIRs of testicular seminoma were seen amongst cooks and stewards (SIR 0.56, 95% CI 0.29–0.98), and forestry workers (SIR 0.64, 95% CI 0.47–0.86). The occupational category of administrators was the only one with a significantly elevated SIR for testicular non‐seminoma (SIR 1.21, 95% CI 1.04–1.42). The only SIRs significantly <1.0 were seen amongst engine operators (SIR 0.60, 95% CI 0.41–0.84) and public safety workers (SIR 0.67, 95% CI 0.43–0.99).

Conclusions

There have always been differences in the incidence of testicular cancer between the Nordic countries. There is also some divergence in the incidences in different age groups and in the trends of the incidence. The effect of occupation‐related factors on incidence of testicular cancer is only moderate. Our study describes the differences, but provides no explanation for this variation.

Editorial: Occupational exposure and risk of testicular cancer: what can an ecological study in the Nordic countries tell us?

Examining the association between occupational exposure and incidence rates of testicular cancer over time in several countries may provide useful insights into the relative importance of lifestyle and environmental risk factors. The study by Ylonen et al. [1] assessed an ecological, rather than biological, effect of occupational exposure in order to understand differences in testicular cancer rates among populations; therefore, the authors could not draw causal inferences about the effect of occupational exposure on testicular cancer at the individual level [2]. Ecological studies are, however, a way of performing hypothesis‐generating population‐based research. They take advantage of the natural experiment following the changes in occupational exposure across countries [3].

Keeping the strengths and limitations of an ecological study design in mind, we should consider what can we learn from the study by Ylonen et al. [1]. Firstly, it is interesting to note that the authors themselves state in their discussion that ‘occupational exposure is probably not relevant’ for testicular cancer because the disease ‘is mainly diagnosed in young adults and the duration of occupational exposure before cancer diagnosis is short’. This highlights the fact that occupational exposure should probably be considered here as a proxy variable for other risk factors of testicular cancer: environmental exposure, physical activity, education, etc. This large study based on linkages of high‐quality data registers therefore merely aims to generate hypotheses. No clear patterns were observed, however, and future studies may benefit from similar ecological approaches using risk factors with a better rationale in the context of the aetiology of testicular cancer, such as socio‐economic statuts, diet or body mass index.

Secondly, the authors also note that this lack of unambiguous risk determinants and underlying mechanisms of testicular cancer makes it difficult to explain the geographic and temporal variations observed [1]. As the study did not have a hypothesis a priori, we find ourselves in a situation where occupational exposure may not be the best risk factor to examine in relation to risk of testicular cancer in an ecological study. The rationale for choosing occupational exposure as the risk factor is weak, and perhaps the authors would have been able to observe more clear patterns if they had conducted the study to assess bladder cancer, for which occupation has been a much more established risk factor and time to exposure has been found to be more relevant.

Thirdly, a clinical understanding of testicular cancer detection may inform changes in incidence over time and between countries. No additional information was provided by the authors, but changes in raising awareness of potential symptoms may have resulted in an increased incidence in a specific age group and/or country. Moreover, it would be of interest to know about differences among countries in terms of occupational exposure groups as this may also explain some of the patterns observed. A further assessment of the characteristics of different categories of occupational exposure could inform the patterns observed in this study and may shed light on the aetiology of testicular cancer.

In conclusion, ecological studies force us to think carefully about patterns of cancer incidence over time and among countries. Unfortunately, the findings cannot always lead to further hypotheses and careful consideration about potential risk factors needs to occur before conducting analyses. Moreover, detailed (clinical) knowledge is required about changes in diagnostic activity over time as well as potential changes in risk factor exposure. Future ecological studies using highly valuable resources, such as those used by Ylonen et al. [1] can help us understand cancer aetiology and prevention in more detail. They can be considered as a natural experiment to fill the gap in our understanding of the link between potential risk factors and risk of developing cancer.

Mieke Van Hemelrijck
Translational Oncology & Urology Research, Kings College
London, London, UK

 

References

1 Ylonen O, Jyrkkio S, Pukkala E, Syvanen K, Bostrom P. Time trends and occupational variation in the incidence of testicular cancer in the Nordic countries. BJU Int 2018; 122: 384–93

2 Morgenstern H. Ecologic studies. In Rothman K, Greenland S eds, Modern Epidemiology, 2nd edn, Philadelphia, PA: Lippincott Williams &Wilkins, 1998: 511–31

3 Sedgwick P. Ecological studies: advantages and disadvantages. BMJ 2014; 348: g2979

 

Editorial: Human development and its impact on genitourinary cancers

Using the extensive data from the WHO International Agency for Research on Cancer and the United Nations Human Development Report, Greiman et al. [1] aimed to investigate how human development is associated with incidence and mortality of genitourinary cancers. Even though they generate some interesting descriptive findings, we have to remain critical of these descriptive statistics and carefully assess what needs to be investigated next.

Firstly, despite having highlighted the need for attention to indicators of longevity, education, and income per head when assessing human development, the human development index (HDI) is a rather crude measurement. As a geometric mean of normalised indices for each of these three domains, the HDI simplifies but only captures part of what human development entails. Important indicators of health care such as inequalities, poverty, human security, and empowerment are not reflected in the HDI (www.hdr.undp.org). In the context of cancer incidence and mortality this is an important limitation, as it has for instance been shown that socioeconomic status affects early phase cancer trial referrals, which can be considered as a proxy for access to health care [2]. This inequality has been hypothesised to be linked to more comorbidities and lower education in those who are most deprived – a complex interaction which may not be completely captured by the HDI.

Secondly, registration of incidence and mortality of cancers may vary substantially between countries based on both medical practice and governance. These differences are important when trying to generate hypotheses following the ecological study of Greiman et al. [1]. In the case of bladder cancer, for instance, mortality has been estimated to be 17% in the Netherlands, compared to 22% in the USA, and 50% in the UK. As cancer treatments are expected to be similar in these developed countries, it has been thought that a lower registration of non-muscle-invasive bladder cancer in the UK could explain this higher proportion [3]. Thus, discrepancies in cancer registration, even between developed countries, may limit our awareness of cancer burden.

Thirdly, the study design suffers from ‘ecological fallacy’. The latter refers to the inability to draw causal inference about the effect of the HDI on genitourinary cancer at the individual level, in conjunction with the underlying problem of heterogeneity of exposure levels [4]. This limitation was not mentioned by Greiman et al. [1], but affects their conclusions. The lack of information on, for instance, smoking data, comorbidities, and ethnicity make it difficult to understand how development is affecting cancer incidence or mortality. It would have been interesting to also investigate cancers other than genitourinary cancers because a comparison of different tumour types might have shed light on differences in medical practice or risk factors across countries and help tease out the ecological effect of human development.

Despite the aforementioned limitations, the descriptive analysis by Greiman et al. [1] can be helpful for generating hypotheses – as also outlined by the authors. This ecological effect of human development on incidence and mortality rates of genitourinary cancers is particularly relevant when evaluating the impacts of prevention and intervention programmes for these cancers. Their findings suggest that further investigation is required to examine the hypothesis regarding human development and incidence/mortality of genitourinary cancers. To further elucidate this association, methodological challenges will need to be overcome, as HDI assessment has been criticised for being too crude. Nevertheless, it should be possible to collect more detailed information to allow for an understanding of which components of a country’s collective resources affect cancer incidence and mortality the most, e.g. differences in resources used for cancer detection and treatment.

Mieke Van Hemelrijck
Division of Cancer Studies, Translational Oncology and Urology Research (TOUR), Kings College London, London, UK

 

References

 

1 Greiman AKRosoff JSPrasad SM. Association of Human Development Index with global bladder, kidney, prostate and testis cancer incidence and mortality. BJU Int2017; 120: 799-807

 

2 Mohd Noor A Sarker DVizor S et al. Effect of patient socioeconomic status on access to early-phase cancer trials. J Clin Oncol 2013; 31: 224– 30.

 

3 Boormans JLZwarthoff EC. Limited funds for bladder cancer research and what can we do about it. Bladder Cancer 2016; 2: 4951

 

4 Morgenstern H . Ecologic studies in epidemiology: concepts, principles, and methods. Annu Rev Public Health 1995; 16: 618

 

In Defence of Lance…

As this year’s Tour de France starts and we wonder if Chris Froome can take over from Sir Bradley this blog thinks about previous Tours with some sadness. As an oncologist treating testicular cancer the Tour used to be a reminder of one of the great successes of modern oncology. Seeing Lance Armstrong on the podium showed how chemotherapy can overcome even poor prognosis testicular cancer. Lance was an inspiration to our patients. I doubt there has been a happier sight on the chemotherapy day unit at Guy’s Hospital than seeing the young men cheer Lance as he surged past Jan Ullrich, whilst they were receiving their chemotherapy.

So rather than become too melancholy I thought I would use this blog to provide a little balance to all the stick Lance has been taking. Whilst Lance as a cyclist is tarnished forever, the other aspect of his story seems to have been forgotten. The incredible part is that he overcame such aggressive disease and was able to ride competitively. He should therefore remain an inspiring figure for those of us treating testicular cancer, and more importantly for young men battling this disease. Whilst as oncologists we quote impressive survival figures, for patients an example of someone who has survived is far more tangible.

So I have been re-reading ‘It’s not about the bike’ (how ironic that title seems now!). The chapters dealing with diagnosis, treatment and recovery are informative and remain inspiring. It’s easy to see why it became and could still be a touchstone for young men battling testicular cancer.

Whilst many will argue that Armstrong’s well publicised battle against cancer was just part of his ego let’s not forget that it takes guts in the macho world of professional sport to admit illness and potential weakness. Many famous men have been affected by cancer but all too often don’t feel able to talk about it or use their position in a positive way. Armstrong was the polar opposite, happy to provide inspiration and also to raise millions for his cancer charity. He also raised the profile of testicular cancer and the need for ongoing research and there remain many important unanswered questions in this disease:

  • Who need’s adjuvant treatment?
  • What adjuvant treatment should we give?
  • How to minimise toxicity of treatment?
  • Long term toxicity and survivorship issues
  • Why are some patients’ cisplatin insensitive?
  • The role of RPLND and metastatectomy
  • The best second line chemotherapy
  • And many others…..

TUF Cycling Across the Andes: More intrepid cyclists supporting research into urological cancers. For more information visit www.theurologyfoundation.org or www.actionforcharity.co.uk.

So as this year’s Tour de France winds its’ way towards those punishing Alpine stages perhaps we should draw a line and move back to Armstrong as the inspiration for the next generation of men with testicular cancer. I for one will always enjoy that ascent on Alpe D’Huez and how it shows we can over come even the worst disease. So Lance your boys still need you! It’s time to eat a very large slice of humble pie and rewrite the book, warts and all, so that you can be an inspiration to the next generation of men with testicular cancer.

Simon Chowdhury is a Consultant Medical Oncologist at Guy’s, King’s and St Thomas’ Hospitals, London. He is actively involved in clinical trial research into urological cancers.

 

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