Long-term side effects of treatment for testis cancer

International evaluation of the psychometrics of health-related quality of life questionnaires for use among long-term survivors of testicular and prostate cancer

Background

Understanding of the physical, functional and psychosocial health problems and needs of cancer survivors requires cross-national and cross-cultural standardization of health-related quality of life (HRQoL) questionnaires that capture the full range of issues relevant to cancer survivors. To our knowledge, only one study has investigated in a comprehensive way whether a questionnaire used to evaluate HRQoL in cancer patients under active treatment is also reliable and valid when used among (long-term) cancer survivors. In this study we evaluated, in an international context, the psychometrics of HRQoL questionnaires for use among long-term, disease-free, survivors of testicular and prostate cancer.

Methods

In this cross-sectional study, we recruited long-term survivors of testicular and prostate cancer from Northern and Southern Europe and from the United Kingdom who had participated in two phase III EORTC clinical trials. Participants completed the SF-36 Health Survey, the EORTC QLQ-C30 questionnaire, the QLQ-PR25 (for prostate cancer) or the QLQ-TC26 (for testicular cancer) questionnaires, and the Impact of Cancer questionnaire. Testicular cancer survivors also completed subscales from the Nordic Questionnaire for Monitoring the Age Diverse Workforce.

Results

Two hundred forty-two men (66% response rate) were recruited into the study. The average time since treatment was more than 10 years. Overall, there were few missing questionnaire data, although scales related to sexuality, satisfaction with care and relationship concerns of men without partners were missing in more than 10% of cases. Debriefing showed that in general the questionnaires were accepted well. Many of the survivors scored at the upper extremes of the questionnaires, resulting in floor and ceiling effects in 64% of the scales. All of the questionnaires investigated met the threshold of 0.70 for group level reliability, with the exception of the QLQ-TC26 (mean reliability .64) and the QLQ-PR25 (mean reliability .69). The questionnaires were able to discriminate clearly between patients with and without comorbid conditions.

Conclusions

The currently available HRQoL questionnaires exhibit acceptable psychometric properties and were well received by patients, but additional efforts are needed to ensure that the full range of survivor-specific issues is assessed.

Testing testes: problems and recent advances in the diagnosis of testicular tumours and implications for treatment

The low incidence of testicular tumours and the fact that they show an extremely high diversity means that they may be poorly understood. Knowledge of the range of tumours and the differences in treatment available is essential for appropriate management. The advent of cisplatin chemotherapy and the exquisite sensitivity of seminoma to radiotherapy have resulted in excellent cure rates. Nevertheless, research has continued unabated, particularly to understand the molecular basis of germ cell tumours and why certain tumours are recalcitrant to treatment. This overview is an attempt to demystify areas of confusion and highlight areas of current interest in testicular pathology and oncology.

Quality of life among testicular cancer survivors: a case-control study in the United States

INTRODUCTION

Evidence from previous studies has suggested there may be physical and mental changes in health among testicular cancer survivors. No studies have been conducted in the United States, however.

METHODS

Study participants were initially enrolled in the US Servicemen's Testicular Tumor Environmental and Endocrine Determinants (STEED) study between 2002 and 2005. A total of 246 TGCT (testicular germ cell tumor) cases and 236 non-testicular cancer controls participated in the current study, and completed a self-administered questionnaire. Mean time since diagnosis for cases was 14 years, and no less than five for all cases. Component scores determined from responses to questions about physical and mental health on SF36 were tabulated to yield two summary measures, physical component scores (PCS), and mental component scores (MCS). Component and summary scores were normalized to a score of 50 with a standard deviation of 10 by a linear T-score transformation.

RESULTS

Overall, cases may not suffer greatly in different quality of life than controls. When all cases and controls are compared, TGCT cases had lower PCS (mean: 51.9 95% CI: 50.6-53.2, P value: 0.037) than controls (mean: 53.6 95% CI: 52.7-54.6). MCS were not significantly different (P value: 0.091). In multivariate analyses, several physical health components were worse for TGCT cases such as role-physical (OR 1.19, 95% CI: 1.01-1.39) and general health (OR 1.26, 95% CI: 1.07-1.49) compared to controls. However, TGCT cases treated with chemotherapy had lower PCS (cases: 50.2, 95% CI: 47.6-52.8; controls: 53.6, 95% CI: 52.7-54.6, P value: 0.0032) and MCS (cases: 49.3, 95% CI: 46.5-52.1; controls: 52.0, 95% CI: 50.9-53.2, P value: 0.039). TGCT cases who received treatments other than chemotherapy did not differ from controls in either PCS or MCS.

DISCUSSION

Physical and general health limitations may affect testicular cancer survivors. Men treated with chemotherapy, however, may be most likely to suffer adverse health outcomes due to a combination of body-wide effects on physical and mental factors which affect various aspects of physical health, mental health, and overall quality of life. And in particular, physical functioning, role-physical, and general health are strongly affected.

The Quality of Life and Hormonal Disturbances in Testicular Cancer Survivors in Cisplatin Era

OBJECTIVES

To assess the degree of hormonal abnormalities in testicular cancer survivors and the effect of these changes on patients' quality of life.

METHODS

Men with complete remission of testicular cancer for over 2 yr were eligible. Patients completed the State-Trait Anxiety Inventory (STAI), the Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), the International Index of Erectile Function (IIEF), and the Sexual Functioning Questionnaire (SFQ), and rated their physical and psychological well-being, quality of life, and relationship with their partner. Levels of the hormones testosterone, estradiol, thyreotropin, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin were determined. Relationships between hormone levels and questionnaire results were assessed.

RESULTS

A total of 326 men were tested, of whom 269 were treated with platinum-based chemotherapy. The most common endocrine abnormalities were above-normal gonadotropin levels (LH, 55%, and FSH, 49% of cases) and lowered testosterone (15%). Twenty-seven percent (STAI) and 28% (HADS) of the patients had abnormal anxiety levels, while the depression rate was 15% (BDI) and 18% (HADS); 40% of patients had erectile dysfunction. Linear regression analysis excluding the influence of age showed higher depression levels in the BDI among patients with elevated LH (p=0.010) or FSH (p=0.017). Patients with above-normal LH showed increased sexual problems in the SFQ (p=0.030). Elevated gonadotropins correlated with deteriorated physical well-being (p=0.028). Men with abnormal estradiol were more prone to erectile dysfunction (p=0.009).

CONCLUSIONS

Hormonal abnormalities have a negative impact on the quality of life of testicular cancer survivors.

Short- and long-term complications of therapy for testicular cancer

We review the treatments used for testicular cancer and the complications associated with each modality of therapy. It is imperative the clinician recognize possible treatment-related morbidity when counseling and monitoring testicular cancer patients.

Two cycles of cisplatin-based chemotherapy for low-volume retroperitoneal stage II nonseminomatous germ cell tumours

OBJECTIVE

To evaluate the oncological efficacy of reducing cisplatin-based chemotherapy to two cycles in patients with low-volume retroperitoneal stage II nonseminomatous germ cell tumours (NSGCTs).

PATIENTS AND METHODS

From October 1988 until January 2004, two cycles of cisplatin-based chemotherapy were administered in 59 patients with low-volume retroperitoneal clinical stage II NSGCT (retroperitoneal mass of <5 cm in diameter). Regardless of remission detected on computed tomography, 6 weeks after chemotherapy the patients had a retroperitoneal lymph node dissection (RPLND) to assess residual active tumour or mature teratoma (open modified bilateral RPLND until 1992, then laparoscopic unilateral template RPLND).

RESULTS

The chemotherapy was effective, as no active tumour was found in any of RPLND specimens. Mature teratoma was present in lymphatic tissue in 23 of 59 patients (39%). In one patient there was a pulmonary recurrence, successfully treated with cisplatin-based salvage chemotherapy. One patient died from an accident but with no evidence of tumour, and 56 patients remained free of disease at a mean follow-up of 98.6 months. No patient died from disease. All patients had antegrade ejaculation after laparoscopic RPLND, as did 89% after open RPLND.

CONCLUSION

In this pilot study, the oncological efficacy of two cycles of cisplatin-based chemotherapy was favourable, but this approach still cannot be recommended as a standard treatment for patients with low-volume retroperitoneal stage II disease. RPLND after chemotherapy has diagnostic (detecting active tumour) and therapeutic (removing mature teratoma) value and can be done laparoscopically. Based on the present results a prospective randomized trial seems reasonable.

Quality of life in survivors of testicular cancer

The objective of this review was to give an overview of findings concerning quality of life (QOL) in general as well as its domains in survivors of testicular cancer. QOL on the group level was equal to that of men of the same age in the general population. Treatment strategies hardly influenced the QOL. The anxiety level, but not depression, was higher among survivors, while sexual functioning hardly differed from the male population norm. Patients to be treated for testicular cancer should be told about the outlook for good QOL, and the low risk of mental and physical long-term effects.

Testicular tumours (nonseminomatous)

In view of the excellent results of multimodal therapy for nonseminoma testicular tumours, with chemotherapy and surgery, attempts have been made to reduce the side-effects of treatment in patients with a good prognosis, while maintaining efficacy. It is now generally accepted that surveillance after orchidectomy is suitable in patients with low-risk stage I disease. Nerve-sparing retroperitoneal lymph-node dissection as a primary treatment is a good alternative to primary chemotherapy in low-stage disease, i.e. high-risk stage I and stage IIa-b, enabling chemotherapy to be reduced by at least half, and decreasing the long-term side-effects of chemotherapy, especially cardiovascular, neuro-, nephro- and pulmonary toxicity. However, in patients with advanced disease and a poor prognosis, conventional chemotherapy is more likely to fail, and improving the treatment results by new schedules of chemotherapy (although more toxic) remains the main goal.

Fatigue, anxiety, and depression in long-term survivors of testicular cancer

PURPOSE

To investigate the prevalence of chronic fatigue (CF), the levels of anxiety and depression, and the correlation between these conditions in long-term survivors of testicular cancer (TCSs). Occurrence of CF in TCSs is compared with findings in male survivors of Hodgkin's disease (HDSs) and in males from the general population (GenPop).

METHODS

TCSs, HDSs, and two cohorts of the GenPop completed the Fatigue Questionnaire (FQ) and the Hospital Anxiety and Depression Scale (HADS) as part of a questionnaire survey. Cases of CF were identified according to published cut-offs, and the levels of anxiety (HADS-A) and depression (HADS-D) were calculated.

RESULTS

Among 791 TCSs, 16% displayed CF (HDSs, 24%; GenPop, 10%). In the age group younger than 30 years, the prevalence of CF was higher in TCSs than in the GenPop (P <.01). In TCSs, age, anxiety, depression, and comorbidity were independent predictors of CF. The mean HADS-A score in TCSs was significantly above the comparable figure of the GenPop and similar to that of HDSs. The mean HADS-D score in TCSs was below that of the GenPop. The highest and lowest mean scores of HADS-A and HADS-D were observed in the youngest TCSs.

CONCLUSION

The prevalence of CF is less in TCSs than in HDSs but exceeds that of the GenPop. Together with comorbidity and age, anxiety and depression predict CF in TCSs, warranting psychiatric intervention for cases of CF among TCSs. Anxiety is a larger problem in TCSs than depression, particularly among the youngest TCSs.

Quality of life in good prognosis patients with metastatic germ cell cancer: a prospective study of the European Organization for Research and Treatment of Cancer Genitourinary Group/Medical Research Council Testicular Cancer Study Group (30941/TE20)

PURPOSE

To describe global quality of life (GLQL) in patients with metastatic testicular cancer (TC) treated with four different schedules of bleomycin, etoposide, and cisplatin (BEP) chemotherapy (four v three cycles given over 5 v 3 days).

PATIENTS AND METHODS

Quality-of-life data were prospectively collected in 666 patients with metastatic TC entered into the European Organization for Research and Treatment of Cancer (EORTC) Trial 30941/United Kingdom Medical Research Council Trial TE20, using the EORTC Quality-of-Life Questionnaire C30 and a TC module. Data were analyzed by a mixed effects model and by evaluation of clinically relevant changes at 2 years.

RESULTS

The pattern of GLQL changes was similar in the four groups. Two years after chemotherapy, 36% of patients displayed improved GLQL as compared with baseline, whereas GLQL had deteriorated in 13%. At 3 months, patients receiving the 3-day regimen experienced increased gastrointestinal (GI) toxicity more than those receiving the 5-day regimen, with the difference reaching the level of clinical relevance (>or = 10-point change) if four cycles were given. The 3-day schedule increased the 2-year risk of tinnitus, with clinical relevance demonstrated after four cycles. Long-term peripheral neuropathy and Raynaud-like phenomena were not associated with the number of cycles or days per cycle. At 2 years, Raynaud-like phenomena, tinnitus, or reduced hearing were reported by 21% to 26% of the patients.

CONCLUSION

Because of the excess of acute GI toxicity and the increased risk of tinnitus after the 3-day regimen, we recommend the 5-day regimen if four cycles of BEP are planned. If only three cycles are to be given, then the 3-day regimen is acceptable, even given the increased risk of nausea/vomiting at 3 months.

Long-term experience with carboplatin monotherapy for clinical stage I seminoma: a retrospective single-center study

OBJECTIVES

To evaluate the long-term oncologic efficacy and morbidity of carboplatin monotherapy, which was introduced at our department 11 years ago for the treatment of Stage I seminoma. Radiotherapy is the standard treatment of patients with clinical Stage I seminoma. Carboplatin has been advocated as a treatment alternative to avoid the late side effects of radiotherapy and the high recurrence rate of surveillance strategies.

METHODS

From February 1990 until August 2001, 108 patients received two adjuvant cycles of single-agent carboplatin (400 mg/m2 body surface on days 1 and 22) 2 weeks after high inguinal orchiectomy. To assess for myelosuppression, complete blood counts were performed at least once a week until the nadir occurred after the second treatment cycle.

RESULTS

During a mean follow-up period of 59.8 months (range 6 to 134), 2 patients (1.85%) developed a recurrence (retroperitoneal tumor) within the first year. Both patients received cisplatin-based salvage chemotherapy. At last follow-up, all patients were alive without any evidence of disease. Carboplatin treatment was well tolerated by all patients and was associated with only mild gastrointestinal side effects. Leukopenia was noted in 32 patients (29.6%); 21 (19.4%) of these patients had World Health Organization (WHO) grade 1, 8 (7.4%) had grade 2, 3 (2.8%) had grade 3, and none had grade 4. No patient developed neutropenic fever. Thrombocytopenia was observed in 48 patients (44.4%); of these patients, 38 (35.2%) had WHO grade 1, 5 (4.6%) had grade 2, 2 (1.9%) had grade 3, and 3 (2.8%) had grade 4.

CONCLUSIONS

From an oncologic standpoint, two cycles of carboplatin monotherapy was highly effective and very well tolerated by all patients.

Self-perceived physical, psychologic, and general symptoms in survivors of testicular cancer 3 to 13 years after treatment

Due to the large group of patients with advanced testicular cancer now being cured, it is important to identify the men who are at risk of deteriorated health. The purposes of this study were: (1) to delineate and compare frequency of self-perceived physical, psychologic, and general symptoms in men treated for testicular cancer with those of a general population sample and (2) to compare self-perceived physical, psychologic, and general symptoms in relation to secondary Raynaud phenomena, sexual dysfunction, infertility, and self-perceived attractiveness in different treatment modalities. The subjects were 277 survivors of testicular cancer (M = 42.2 years) who had completed a self-reported questionnaire (75.5% response rate). A population survey comprising 392 men was used as a comparison group (M = 45 years). The result demonstrated that although survivors of testicular cancer as a group reported significantly less frequency of backache, leg pain, cough, and eye problems than did the general population sample, they described that they significantly more often felt cold. Men reporting secondary Raynaud phenomena, infertility, and/or feeling less attractive had experienced significantly more self-perceived symptoms. Oncologist nurses could play an important role in psychologic counseling for those men.

Short Form 36 and Hospital Anxiety and Depression Scale. A comparison based on patients with testicular cancer

BACKGROUND

The aim of this study was to compare the scorings of anxiety and depression assessed by the Hospital Anxiety and Depression Scale (HADS-A [Anxiety] and HADS-D [Depression]) with the scorings on the eight subscales of Short Form 36 (SF-36) and the Physical (PCS) and Mental Component Summary (MCS) assessed by the same patients.

METHOD

In a cross-sectional study 736 long-term survivors after treatment for testicular cancer (TC) completed HADS and SF-36. Pearson's correlation coefficients were calculated on item and scale level to assess the associations between the HADS and the SF-36 scales and, in particular, between HADS and PCS and MCS, respectively. Independent predictors for PCS and MCS were identified by linear regression analysis.

RESULTS

HADS-A and HADS-D were significantly associated with the SF-36 summary scales. HADS-A explained 5% of the variance of PCS and 49% of the variance of MCS. The comparable figures for HADS-D were 10% and 45%, respectively. In the multivariate analysis the HADS-D scoring independently predicted the level of PCS together with the patients' educational level, long-lasting working disability and age (variance: 30%). Both HADS-D and HADS-A remained independent parameters for MCS (variance: 58%) together with the patient's civil status. HADS-D item D4 ("slowed down") was similarly associated with both PCS and MCS.

CONCLUSION

In univariate analyses HADS-D and HADS-A were statistically associated with PCS and MCS. The highest r values were observed for the associations between HADS and MCS, in particular between HADS-A and MCS. In the multivariate analyses HADS-D, but not HADS-A, contributed to PCS, whereas both HADS-A and HADS-D were associated with MCS. This pattern of different predictions of the summary scales of SF-36 supports a clinical practice that anxiety and depression should be assessed separately. Additional use of a self-rating instrument for depression and anxiety, such as HADS, is recommended when SF-36 is used for quality of life (QL) assessment.

P53 and Fas are sequential mechanisms of testicular germ cell apoptosis

Testicular germ cell apoptosis in the cryptorchid testis is induced by abdominal heat stress. p53-dependent apoptosis appears responsible for the initial phase of germ cell loss in experimental cryptorchidism based on a 3-day delay of apoptosis in p53-/- mice. However, the mechanisms underlying the subsequent p53-independent apoptosis have not been identified. Although studies have suggested that Fas plays a role in testicular germ cell apoptosis, no direct evidence has been shown. To test the hypothesis that Fas is involved in testicular germ cell apoptosis and is responsible for the p53-independent phase of apoptosis in the cryptorchid testis, p53-/-, lpr/lpr (a spontaneous mutation in the Fas gene, which causes autoimmune disease) double-mutant mice were generated and unilateral cryptorchidism was induced in these mice. It was found that testicular weight reduction and germ cell apoptosis were delayed by an additional 3 days, and the Fas production increased in the time frame of p53-independent apoptosis in the experimental cryptorchid testis of wild-type mice. These results suggest that Fas is involved in testicular germ cell apoptosis, and that Fas-dependent apoptosis is responsible for the p53-independent phase of germ cell apoptosis in the cryptorchid testis. The cascade of testicular germ cell apoptosis in response to heat stress implies the existence of sequential quality control mechanisms in spermatogenesis.

Quality of life in long-term survivors of testicular cancer: a population-based case-control study

PURPOSE

To evaluate quality of life and social problems in long-term survivors of testicular cancer.

PATIENTS AND METHODS

In 1998, 71 testicular cancer survivors (cases) identified from the Calvados General Tumor Registry were enrolled onto a case-control study. One hundred nineteen healthy control subjects (controls), matched by age and location of residence, were selected at random from electoral rolls. Three self-administered questionnaires were used: two health-related quality-of-life questionnaires (Short Form-36 and European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-C30 core questionnaires) and one life situation questionnaire. Specific questions concerning sexuality were also added.

RESULTS

With a mean follow-up of 11 years, health-related quality-of-life scores did not differ significantly between cases and controls, nor did general symptom scores. Psychosocial problems were reported equally by cases and controls. Cases reported more modification of sexual life (P =.04) with decreased sexual enjoyment (P <.01), decreased desire (P =.02), and infertility (P <.01). Cases did not report more divorce than controls; they reported fewer changes in relationships with friends (P =.03). Although a similar proportion of cases and controls were at work, cases expressed less ambitious professional plans (P =.002). Cases had greater difficulty in borrowing from banks (P <.001).

CONCLUSION

French long-term survivors of testicular cancer do not express more impairment of health-related quality of life or familial or professional life in comparison with healthy men. They did have more sexual life problems and found difficulty in borrowing from banks. This information should be used by practitioners to help their patients cope with their disease and return to normal life.

Management of low-stage nonseminomatous germ cell tumors of the testis

Testicular cancer has become one of the most curable of all solid neoplasms. High cure rates associated with modern treatment regimens for low-stage testis cancer have resulted in a shift in focus toward reducing morbidity of potentially toxic treatment regimens.

Peri-operative care in patients treated for testicular cancer

The success of combination chemotherapy in treating advanced metastatic germ cell tumors has led to new challenges for the genitourinary oncologic surgeon in the peri-operative care of patients. Surgery remains an integral part of the management of patients with advanced germ cell tumors. Retroperitoneal node dissections following chemotherapy or radiation, or both, are technically more demanding and subject to higher rates of peri-operative complications. Overall post-therapy surgical complication rates range from 33% to 75%, with the highest rates among patients who receive both radiation and chemotherapy. Although most patients with testicular cancer are young and healthy, residual pulmonary, renal, vascular, and neurologic toxicities from chemotherapy can increase the risk of peri-operative complications. In addition, the volume and location of tumor can increase the technical demands, especially when there is a tremendous soft tissue reaction to the chemotherapy. Identification of pre-operative risk factors for peri-operative complications is imperative and the first step in pre-operative planning. Pulmonary toxicity and vascular (cardiac or peripheral) events are the two most immediately life-threatening complications that can occur in the peri-operative period. Due to the high incidence of subclinical pulmonary toxicity, one must consider all patients who have received bleomycin pre-operatively at risk to develop postoperative pulmonary problems. Pre-operative evaluation and judicious fluid management have been shown to reduce the risk of life-threatening respiratory complications in the postoperative period.

Health-related quality of life in patients treated for testicular cancer

Cross-sectional studies have shown that long-term health-related quality of life is satisfactory in the majority of testicular cancer patients, in spite of slight to moderate physical morbidity (sexual dysfunction, infertility) in at least a third of them. Modern risk-adapted treatment of testicular cancer patients will hopefully decrease the long-term sequelae furthermore. Prospective studies are needed to identify those patients at increased risk of developing major physical or psychosocial problems, and to study the role of medical and psychological intervention at an early phase of the clinical course in these patients. The long-term investigation and follow-up of testicular cancer survivors provide useful information on survivorship problems in cured cancer patients in general.

Stage II nonseminomatous testis cancer: the roles of primary and adjuvant chemotherapy

Historically, a retroperitoneal lymph node dissection (RPLND) has been the primary treatment of stage II nonseminomatous germ cell tumor (NSGCT) patients, whereas chemotherapy has been used in the adjuvant setting. Increasing evidence of the efficacy of chemotherapy has led to additional treatment possibilities for stage II patients. Both chemotherapy and RPLND have a role in the primary therapy of stage II NSGCT, and both modalities can be used as secondary adjunctive therapy. Management of these patients now requires a renewed emphasis on risk stratification and on the integration of patient preferences into the management algorithm.