Differences at Presentation and Treatment of Testicular Cancer in Hispanic Men: Beyond the Abstract

Testicular germ cell tumors (TGCTs) are the most common solid malignancy in young men in the United States(1). While our institution in Texas has historically cared for a large Hispanic population, this population is the fastest growing nationwide(2). In fact, modeling of increased incidence rates forecast that the rates of TGCT in Hispanic men would surpass that of non-Hispanic whites (NHW) by 2026(3). Given this rapid growth, we sought to evaluate the sociodemographic and clinicopathologic differences between Hispanics and NHW patients with TGCT both at our own institution and the National Cancer Database (NCDB).

In our institutional cohort we identified that 41% of TGCT patients were Hispanic; and these patients were significantly younger at presentation by about 5 years (p<0.001) but delayed in seeking care from onset of symptoms (63 vs 28 days, p=0.019). Hispanic patients were more likely to present through the emergency room (p<0.001) and be cared for at the county hospital (p<0.001).

A review of nationwide data in the NCDB, identified 62,727 testicular tumor patients of whom 11% were Hispanic. Again, Hispanic patients presented at a significantly younger age by about 5 years (p<0.001). With regards to socioeconomic factors, Hispanic patients were less likely to be insured privately and more likely to be uninsured, and reside in less educated and less wealthy zip codes. Additionally, Hispanics were more likely to be diagnosed with non-seminomatous germ cell tumors (NSGCT) compared to NWH patients (52% vs 42%, p<0.001). Of those with metastatic disease, a higher proportion of Hispanic patients were intermediate or poor risk per IGCCCG grouping.

The NCDB was evaluated for potential racial/ethnic disparities in TGCT management. One potential disparity is that the time from clinical diagnosis to surgery (i.e. orchiectomy) was significantly longer for Hispanics as compared to NHW. While it is difficult to determine how socioeconomic factors impact management in a complex disease like TGCT, we focused on several controversial areas. In the NCDB analysis we noted a higher utilization of surveillance in the management of stage IA/IB seminoma and lower rate of performing PC-RPLND for stage II/III NSGCT.

In summary, through an institutional review and validation with a nationwide, hospital-based cancer registry we identified significant difference in the presentation, biology and management of TGCT between Hispanic and NHW men. The diagnosis at a significantly younger age and higher predominance of NSGCT histology by Hispanic patients suggests a biological difference in TGCT between ethnicities. It is therefore imperative that our ongoing efforts to molecularly characterize TGCT include minority races/ethnicities. While difference in management can be due to multiple uncaptured factors, the findings that Hispanics patients are more likely to have unfavorable insurance status, come from lower socioeconomic zip codes and delay in seeking care, raises the possibility of disparity between ethnicities. This is a concern as TGCT is a generally a highly treatable oncologic scenario so long as reliable access to medical care can be obtained. In a political climate where access to healthcare is at the forefront of debate in the US, success stories like TGCT highlight the necessity for access to complex coordinated medical care no matter a patient’s ethnicity or socioeconomic background.

Co-Authors: Aditya Bagrodia, Timothy Clinton, Solomon Woldu 

References:
  1. Society AC. Cancer facts & figures 2016. Atlanta: American Cancer Society. 2016.
  2. Colby SL, Ortman JM. Projections of the size and composition of the U.S. population: 2014 to 2060. Current Population Reports, US Census Bureau, Washington, DC. 2014;P25-1143.
  3. Ghazarian AA, Kelly SP, Altekruse SF, Rosenberg PS, McGlynn KA. Future of testicular germ cell tumor incidence in United States: forecast through 2026. Cancer. 2017;123:2320-8.
  4. Boffa DJ, Rosen JE, Mallin K, Loomis A, Gay G, Palis B, et al. Using the National Cancer Database for outcomes research: a review. JAMA Oncol. 2017;3(12):1722-8.
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