Excessive annual BMI increase after chemotherapy among young survivors of testicular cancer

Energy balance in cancer survivors at risk of weight gain: a review

PURPOSE

The study of energy balance [i.e., energy intake (EI) and energy expenditure (EE)] is a powerful tool for understanding body weight regulation and may contribute to our understanding of rapid weight gain risk in certain cancer survivors post-diagnosis. The purpose of this review was to summarize studies that assessed longitudinal, prospective changes in components of energy balance from diagnosis/start of treatment to any duration of follow-up in cancer survivors with prior evidence of weight gain (breast, prostate, thyroid, gynecologic, testicular, and acute lymphoblastic leukemia) RESULTS: The available literature suggests that energy balance components may be altered in cancer survivors who have a heightened risk of weight gain post-diagnosis. The evidence for EI was overall inconsistent. Conversely, decreases in resting and physical activity EE during the active phases of treatment (e.g., chemotherapy, hypothyroid state) were commonly noted, which then slowly rebounded towards baseline levels at the end of treatment and during follow-up assessments. Much of this evidence is based on data collected from breast cancer survivors, which highlights a paucity of data currently available on other cancer types.

CONCLUSIONS

While there is growing acknowledgement that weight management interventions in cancer survivors are needed, it is important to recognize that changes in both behavioral (EI, physical activity EE) and passive (resting EE, thermic effect of food) components of energy balance may occur post-diagnosis. This information can help to inform weight management interventions which often entail modifications in diet and/or physical activity.

High prevalence of overweight/obesity and dyslipidemia in patients with intracranial germ cell tumors

PURPOSE

To evaluate the prevalence of overweight/obesity and dyslipidemia in patients with intracranial germ cell tumor (iGCT), and to explore the risk factors of it.

METHODS

iGCT patients visiting Peking Union Medical College Hospital between Jan 2008 to Oct 2020 were included. The prevalence of overweight/obesity and dyslipidemia was calculated. Mixed-effects models were used to evaluate the relationship between BMI z-scores, concentration of lipid profiles and potential risk factors.

RESULTS

One hundred and six patients were included. The median follow-up time was 27 (IQR 5-59) months. The number of patients diagnosed with overweight/obesity and dyslipidemia were 49 (46.2%) and 86 (81.1%) during visits. Higher BMI z-scores were associated with treatment (mean difference (MD) 0.51, 95%CI 0.31-0.72), surgical biopsies (MD 0.71, 95%CI 0.16-1.25), adrenal insufficiency (MD 0.37, 95%CI 0.07-0.68), hypothyroidism (MD 0.35, 95%CI 0.06-0.63), glucocorticoid supplementation (MD 0.64, 95%CI 0.40-0.87), and thyroxine supplementation (MD 0.48, 95%CI 0.24-0.72). Hypothalamus involvement was associated with increased TC (MD 0.52, 95%CI 0.06-0.98), TG (MD 0.36, 95%CI 0.01-0.72), LDL-C (MD 0.60, 95%CI 0.20-0.98), and decreased HDL-C (MD - 0.23, 95%CI - 0.44 to - 0.02). Higher TC (MD 0.53, 95%CI 0.26-0.80) and LDL-C (MD 0.39, 95%CI 0.17-0.62) were observed in patients after treatment. Glucocorticoid supplementation was associated with increased TC (MD 0.70, 95%CI 0.38-1.03), LDL-C (MD 0.51, 95%CI 0.24-0.78), and HDL-C (MD 0.25, 95%CI 0.09-0.40), while sex hormone supplementation was associated with decreased TC (MD - 0.74, 95%CI - 1.2 to - 0.29) and TG (MD - 0.47, 95%CI - 0.86 to - 0.08).

CONCLUSION

Overweight/obesity and dyslipidemia were high prevalent in iGCT patients and should be screened during follow-ups.

Body composition changes during and after curative chemotherapy in patients with testicular cancer

BACKGROUND

Testicular cancer is associated with excellent prognosis and cure is achieved in most patients with advanced cancer treated with cisplatin-based chemotherapy. However, testicular cancer survivors are at increased risk of accelerated atherosclerosis, which significantly contributes to their late morbidity and mortality. Atherosclerosis is associated with a higher proportion of fat mass and especially with increased amount of visceral fat. We explored the effects of cisplatin-based chemotherapy on body composition during and after the treatment.

PATIENTS AND METHODS

We studied 30 testicular cancer patients before chemotherapy, after the second cycle of chemotherapy and three months after the end of chemotherapy. Body composition parameters were evaluated using bioelectrical impedance analysis (BIA).

RESULTS

Three months after the end of chemotherapy the fat mass had increased from 22.04±7.15% to 23.92±7.33% (P=0.026) and visceral fat volume had increased by 17% from 2.36±1.75l to 2.77±1.94l (P=0.013). In the whole sample there was a decrease in muscle mass after the second cycle of chemotherapy (-1.33 ± 2 kg on average; P=0.005). The changes in body composition varied according to distinct baseline fat mass.

CONCLUSION

Cisplatin-based chemotherapy was associated with increase of fat mass, visceral fat, and body mass index. We also observed decrease in muscle mass and total body water. Our results suggest that BIA could help to target preventative measures to avert the acceleration of atherosclerosis in patients treated with cisplatin-based chemotherapy.

Long-Term Enteral Nutrition Facilitates Optimization of Body Weight

BACKGROUND

Optimization of body mass index (BMI) among cancer survivors is a priority. Long-term enteral nutrition is required by many head and neck cancer survivors and may be utilized to affect changes in BMI.

METHODS

We used a retrospective review of head and neck cancer survivors dependent on enteral nutrition. Patients were grouped according to their BMI at initiation of enteral feeding. Patients with normal, low, or elevated BMI were assigned a goal of weight maintenance, weight gain, or weight reduction, respectively. Changes in BMI over time were recorded.

RESULTS

We identified 39 head and neck cancer survivors requiring enteral nutrition. Median time on enteral nutrition was 32 +/- 39.6 months. At the initiation of enteral feeding, 51% of patients had a normal BMI and were assigned to the weight maintenance group, 84% successfully maintained a normal BMI (mean 22.4 +/- 1.7 kg/m(2)), and 18% had a low BMI and were assigned to the weight gain group. In all, 85% achieved or trended toward a normal BMI (from 16.5 +/- 1.9 to 19.2 +/- 1.6 kg/m(2); p = .02). When enteral feedings began, 31% of patients had an elevated BMI and were assigned a goal of weight reduction; all were able to reduce their BMI (from 30.2 +/- 5 to 27.3 +/- 6 kg/m(2); p < .001).

CONCLUSIONS

Long-term enteral feeding facilitates body weight optimization among ambulatory head and neck cancer survivors. These findings may potentially be generalized to all ambulatory patients who are dependent on enteral nutrition.

Cardiovascular disease in cancer survivors

Certain cancer therapies, including radiation therapy and some types of chemotherapies, are associated with increased risk of cardiovascular disease (CVD) and events. Some of these effects such as those presented by anthracyclines, radiation therapy, cisplatin, as well as those presented by hormone therapy for breast cancer-usually taken for many years for some breast and prostate cancers-are long-lasting and associated with cardiovascular events risk more than 20 years after cancer treatment. Cardiovascular testing, diagnostic assessment of suspected cardiovascular symptomatology, as well as laboratory tests for CVD risk factors are imperative. The early recognition and treatment of CVD processes that arise in survivorship years is pivotal, with specific attention to some CVD processes with specific suggested treatment modalities. Preventive measures include adequate screening, the use of medications such as ACE inhibitors/angiotensin receptor blockers and/or beta blockers, statin therapy and aspirin in persons who warrant these medications, as well as therapeutic lifestyle modifications such as exercise/physical activity, weight loss and appropriate diet for a healthy lifestyle. Periodic follow-up with a good primary care physician who understands the risks associated with cancer therapy is important, and referral to onco-cardiology for further management of cardiovascular risk in these survivors is based on a patient's cardiovascular risk level and the type, amount and duration of cancer therapies received during the patient's lifetime.

Taste and smell function in testicular cancer survivors treated with cisplatin-based chemotherapy in relation to dietary intake, food preference, and body composition

BACKGROUND

Chemotherapy can affect taste and smell function. This may contribute to the high prevalence of overweight and metabolic syndrome in testicular cancer survivors (TCS). Aims of the study were to evaluate taste and smell function and possible consequences for dietary intake, food preference, and body composition in TCS treated with cisplatin-based chemotherapy.

METHODS

Fifty TCS, 1-7 years post-chemotherapy, and 50 age-matched healthy men participated. Taste and smell function were measured using taste strips and 'Sniffin' Sticks', respectively. Dietary intake was investigated using a food frequency questionnaire. Food preference was assessed using food pictures varying in taste (sweet/savoury) and fat or protein content. Dual-Energy X-ray Absorptiometry was performed to measure body composition. Presence of metabolic syndrome and hypogonadism were assessed.

RESULTS

TCS had a lower total taste function, a higher bitter taste threshold, higher Body Mass Index (BMI), and more (abdominal) fat than controls (p < 0.05). No differences in smell function and dietary intake were found. Testosterone level was an important determinant of body composition in TCS (p = 0.016).

CONCLUSION

Although taste function was impaired in TCS, this was not related to a different dietary intake compared to controls. Lower testosterone levels were associated with a higher BMI, fat mass, and abdominal fat distribution in TCS.

Treatment-related Cardiovascular Toxicity in Long-term Survivors of Testicular Cancer

Backgrounds

Testicular cancer is the most common malignancy in young men. Considering increasing incidence, exceptionally high cure rate, as well as long life expectancy, assessment of long term toxicity in testicular cancer survivors is of great importance. In the last decades a major effort has been made in order to reduce toxicity of treatment, while maintaining its high effectiveness.

Conclusions

Actual knowledge on treatment toxicity is based on outdated treatment modalities. Hopefully, modern treatment modalities could reduce toxicity, but, there is no firm confirmation for that at the moment, as data dealing with late sequelae of modern treatment of testicular cancer are not available yet due to the short period of observation. The life-threatening cardiovascular toxicity in testicular cancer survivors is major complication of platinum-based chemotherapy, mediastinal radiotherapy and even subdiaphragmatic radiotherapy.

Cancer patients' participation in population-based health surveys: findings from the HUNT studies

Background

The magnitude of participation bias due to non-participation should be considered for cancer patients invited to population-based surveys. We studied participation rates among persons with and without cancer in a large population based study, the Nord-Trøndelag Health Study (HUNT).

Methods

Citizens 20 years or above living in the Nord-Trøndelag County of Norway have been invited three times to comprehensive health surveys. The invitation files with data on sex, invitation date and participation were linked to the Cancer Registry of Norway. In a first step unadjusted crude participation rates (participants/invited persons) were estimated for cancer patients (CaPts) and non-cancer persons (NonCaPers), followed by logistic regression analyses with adjustment for age and sex. To evaluate the “practical” significance of the estimated odds ratios in the cancer diagnosis group, relative risks were also estimated comparing the observed rates to the estimated rates under the counterfactual assumption of no earlier cancer diagnosis among CaPts.

Results

Overall 3 % of the participants in the three HUNT studies were CaPts and 59 % of them had been diagnosed with their first life-time cancer >5 years prior to each survey. In each of the three HUNT surveys crude participation rates were similar for CaPts and NonCaPers. Adjusted for sex and age, CaPts’ likelihood to participate in HUNT1 (1984–86) and HUNT2 (1995–97), but not in HUNT3 (2006–2008), was statistically significantly reduced compared to NonCaPers, equaling a relative risk of 0.98 and 0.96, respectively. The lowest odds ratio emerged for CaPts diagnosed during the last 2 years preceding a HUNT invitation. Only one-third of CaPts participating in a survey also participated in the subsequent survey compared to approximately two-thirds of NonCaPers, and 11 % of CaPts participated in all three HUNT surveys compared to 37 % of NonCaPers.

Conclusion

In the three HUNT surveys no or only minor participation bias exist as to CaPts’ participation rates. In longitudinal studies selection bias as to long-term cancer survivorship should be taken into account, the percentage of repeatedly participating CaPts diminishing more strongly than among NonCaPers.

Short- and Long-term weight changes among United States veterans with diffuse large B-cell lymphoma treated with CHOP chemotherapy

Identifying weight changes associated with treatment of diffuse large B-cell lymphoma (DLBCL) has the potential to improve the long-term health of survivors. A retrospective cohort of United States veterans with a new diagnosis of DLBCL between October 1, 1998 and September 30, 2008, with follow-up until April 23, 2013, was assembled. Weight changes were evaluated before, during, and after treatment in 1935 DLBCL patients who received cyclophosphamide, doxorubicin, vincristine, and prednisone, with or without rituximab (CHOP+/- R). One year prior to treatment, 79% of patients were obese or overweight. During the 12 months leading up to treatment, 57% of the cohort lost weight. Among patients surviving 24 months after treatment initiation, weight increased an average of 2.9 kg above weight at treatment completion. The weight change trends observed in these DLBCL patients suggest that weight management strategies may be an important part of long-term survivorship planning after conclusion of treatment.

Information needs of cancer patients and survivors regarding diet, exercise and weight management: a qualitative study

While advanced cancer is often associated with weight loss, curative cancer treatment is often associated with weight gain. Weight gain during treatment may be associated with greater risk of cancer recurrence and development of lifestyle diseases. Currently, limited resources are available to cancer patients focussed on weight control. This study assessed the information needs of patients undergoing curative chemotherapy regarding diet, exercise and weight management for the purpose of developing weight management resources. Focus groups were held with oncology practitioners, patients and survivors to determine current information provision and needs. Focus groups highlighted a perception that information provision regarding diet, exercise and weight management is insufficient and no routine assessment of weight occurs during chemotherapy. Barriers to information provision described included lack of resources and time, and practitioners' uncertainty regarding appropriate messages to provide. Patients wanted more information regarding diet, exercise and weight during treatment time. The findings of this study suggest an increase in provision of diet, exercise and weight management information is needed. This information should be evidence-based and delivered at an appropriate time by the preferred health care professional. It would also be beneficial to implement protocols regarding assessment of weight during treatment.

Prevalence of the metabolic syndrome and cardiovascular disease risk in chemotherapy-treated testicular germ cell tumour survivors

Background:

Testicular cancer patients have an increased risk for cardiovascular disease (CVD), which might be related to the increased prevalence of the metabolic syndrome (MetS) in this group of patients.

Methods:

We assessed the prevalence of MetS and calculated the 10-year CVD risk in a cohort of 255 testicular germ cell tumour survivors (median age, 38.7 years; interquartile range, 31–48) at a mean of 7.8 years after anti-cancer treatment, and compared these with data obtained from 360 healthy men.

Results:

Survivors had an age-adjusted increased risk for MetS of 1.9 compared with that of healthy controls. The risk for MetS was highest in survivors treated with combination chemotherapy (CT) 2.3 (Adult Treatment Panel of the National Cholesterol Education Program classification) and 2.2 (International Diabetes Federation classification). The risk of MetS was especially increased in survivors with testosterone levels in the lowest quartile (OR, 2.5). Ten-year cardiovascular risk as assessed by the Framingham Risk Score (3.0%) and Systemic Coronary Risk Evaluation (1.7%) algorithms was low, independent of treatment, and was comparable to controls.

Conclusion:

Testicular germ cell tumour survivors have an increased prevalence of MetS, with hypogonadism and CT treatment being clear risk factors for the development of the syndrome. The increased prevalence of MetS was not associated with an increased 10-year cardiovascular risk.

Is increased body mass index associated with the incidence of testicular germ cell cancer?

PURPOSE

Epidemiological and ecological evidences suggest a positive association of overweight and obesity with the risk of testicular germ cell cancer (GCC). Previous controlled trials reported conflicting results. The present study aimed to analyse the putative association of overweight with GCC risk in a large patient sample and to summarize previous data.

METHODS

A total of 8,498 GCC patients were enrolled in a nationwide multicentric case control study. Self-reported body dimensions were recorded for calculation of the body mass index (BMI; kg/m(2)). For comparison, 2,070 age-matched male probands of the latest German National Health Survey (NHS) were employed. Patients and controls were categorized according to age as follows: 18-29, 30-39, and 40-49 years, respectively, and according to BMI, as follows: <18.5; 18.5 to <25; 25 to <30; >30 kg/m(2), respectively. Frequencies of BMI-categories in the three age groups were tabulated and compared statistically. The literature was searched for previous controlled trials regarding BMI and GCC risk.

RESULTS

The median BMI of all GCC patients is 24.69 kg/m(2). Overall comparison of frequencies of BMI categories of cases and controls did not reveal any significant difference. However, in young men (18-29 years) BMI categories 25 to <30 kg/m(2) and >30 kg/m(2) were significantly more frequent in GCC patients than in controls (p < 0.00001). Nineteen previous studies were identified in the literature, one of which being clearly in accordance with the present hypothesis, one being antithetical while the remaining studies were inconclusive in various aspects.

CONCLUSION

The results of this population-based study lend support to two hypotheses regarding the pathogenesis of GCC: First, as high-calorie nutrition is the most important reason for increased BMI, it appears conceivable that nutritional factors are involved in the pathogenesis of GCC. Second, as nonseminoma is the most prevalent histological subtype among younger patients, the association of increased BMI with incidence of GCC in this particular subgroup may point to divergent pathogenetic pathways of nonseminoma and seminoma, respectively.

Cardiovascular risk in long-term survivors of testicular cancer

BACKGROUND

Long-term survivors of testicular cancer (TC) who received cisplatin-based chemotherapy have an increased risk of cardiovascular disease. A cross-sectional study was performed to objectively assess cardiovascular risk, subclinical atherosclerosis, and endothelial function in long-term survivors of TC.

METHODS

Long-term survivors of TC underwent evaluation including determination of body mass index (BMI), Framingham relative risk (RR), brachial artery flow-mediated dilatation (FMD), carotid artery intima-media thickness (IMT), soluble intercellular adhesion molecule-1 (sICAM-1), high sensitivity C-reactive protein (hs-CRP), and flow cytometric analysis of peripheral blood for levels of endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs). TC survivors who received chemotherapy were compared with a chemotherapy naive cohort.

RESULTS

Twenty-four patients received cisplatin-based chemotherapy (CBCT) and 15 were chemotherapy-naive (CN). The CBCT cohort demonstrated more impairment of brachial artery FMD than the CN group (5.6% vs 8.8%; P = .05). The mean sICAM was also found to be higher in the CBCT cohort compared with the CN group (P = .04). No significant differences between the groups were noted with regard to BMI, Framingham RR, carotid IMT, or hs-CRP. In a subset of patients, TC survivors who received chemotherapy had a significantly increased level of CECs compared with CN patients (P = .04). No significant difference in EPC levels was detected.

CONCLUSIONS

Long-term survivors of TC who received chemotherapy demonstrate objective evidence of endothelial injury and dysfunction, a potential mechanism for increased cardiovascular risk.

Cardiovascular Risk in Testicular Cancer Survivors Treated With Chemotherapy: Incidence, Significance, and Practice Implications

PURPOSE/OBJECTIVES

To explore what is known regarding cardiovascular late effects of treatment, such as Raynaud phenomenon, hypertension, hyperlipidemia, and coronary artery disease as well as the risk for cardiovascular events experienced by patients with testicular cancer treated with chemotherapy.

DATA SOURCES

Literature review of treatment options and cardiovascular risk in patients with testicular cancer from PubMed, MEDLINE, oncology nursing literature, and the Internet.

DATA SYNTHESIS

Evidence exists that chemotherapy used to treat testicular cancer may increase risk of cardiovascular disease. More research is needed to clarify the risks further. Patients and their healthcare providers must be aware of the potential toxicities.

CONCLUSIONS

A limited but growing body of research is focused on defining cardiovascular risks in this population.

IMPLICATIONS FOR NURSING

Nurses have an important role in exploring and identifying cardiovascular risk factors in patients, furthering research to clarify the risks, and using the knowledge to improve patient care and education.

Long-term risk of cardiovascular disease in 5-year survivors of testicular cancer

PURPOSE

To evaluate the long-term risk of cardiovascular disease (CVD) in survivors of testicular cancer (TC).

PATIENTS AND METHODS

We compared CVD incidence in 2,512 5-year survivors of TC, who were treated between 1965 and 1995, with general population rates. Treatment effects on CVD risk were quantified in multivariate Cox regression analysis.

RESULTS

After a median follow-up of 18.4 years, 694 cardiovascular events occurred, including 141 acute myocardial infarctions (MIs). The standardized incidence ratio (SIR) for coronary heart disease was 1.17 (95% CI, 1.04 to 1.31), with 14 excess cases per 10,000 person-years. The SIR for MI was significantly increased in nonseminoma survivors with attained ages of less than 45 (SIR = 2.06) and 45 to 54 years (SIR = 1.86) but significantly decreased for survivors with attained ages of 55 years or older (SIR = 0.53). In Cox analysis, mediastinal irradiation was associated with a 3.7-fold (95% CI, 2.2- to 6.2-fold) increased MI risk compared with surgery alone, whereas infradiaphragmatic irradiation was not associated with an increased MI risk. Cisplatin, vinblastine, and bleomycin (PVB) chemotherapy (CT) was associated with a 1.9-fold (95% CI, 1.7- to 2.0-fold) increased MI risk, and bleomycin, etoposide, and cisplatin (BEP) CT was associated with a 1.5-fold (95% CI, 1.0- to 2.2-fold) increased CVD risk and was not associated with increased MI risk (hazard ratio = 1.2; 95% CI, 0.7 to 2.1). Recent smoking was associated with a 2.6-fold (95% CI, 1.8- to 3.9-fold) increased MI risk.

CONCLUSION

Nonseminomatous TC survivors experience a moderately increased MI risk at young ages. Physicians should be aware of excess CVD risk associated with mediastinal radiotherapy, PVB CT, and recent smoking. Intervention in modifiable cardiovascular risk factors is especially important in TC survivors. Whether BEP treatment increases CVD risk should be evaluated after more prolonged follow-up.

Acute chemotherapy-induced cardiovascular changes in patients with testicular cancer

PURPOSE

After cisplatin- and bleomycin-containing chemotherapy for testicular cancer, part of the patient population will develop acute or long-term cardiovascular toxicity. It is largely unknown whether standard tests can be used to assess chemotherapy-induced cardiovascular changes.

PATIENTS AND METHODS

In 65 testicular cancer patients (median age, 27 years; range, 18 to 48 years), we measured the following cardiovascular parameters before and within 10 weeks after completion of cisplatin-based chemotherapy: platelet numbers, plasma levels of hemostatic and fibrinolytic factors, 24-hour ambulatory blood pressure, baroreflex sensitivity, intima-media thickness of the common carotid artery, and flow-mediated vasodilation of the brachial artery.

RESULTS

Compared with prechemotherapy values, the intima-media thickness of the carotid artery and plasma von Willebrand factor levels increased significantly after treatment. Platelet numbers and plasma levels of other hemostatic and fibrinolytic factors did not appear to change significantly. Blood pressure decreased significantly, but flow-mediated vasodilation and baroreflex sensitivity did not change.

CONCLUSION

In testicular cancer patients treated with cisplatin-based chemotherapy, we found an increase in plasma von Willebrand factor levels and in the intima-media thickness of the carotid artery. These changes may indicate chemotherapy-induced vascular damage and be of prognostic significance for the development of cardiovascular complications in the long term.

Blood pressure and body mass index in long-term survivors of testicular cancer

PURPOSE

To evaluate blood pressure and body mass index (BMI) in long-term survivors of testicular cancer (TC) treated with different modalities.

PATIENTS AND METHODS

One thousand eight hundred fourteen patients treated for unilateral TC in Norway (1980 to 1994) were invited to participate in a follow-up study (1998 to 2002), including measurements of systolic blood pressure (SBP), diastolic blood pressure (DBP), and BMI. Of these patients, 1,289 patients (71%) participated in the study. The patients were categorized into four treatment groups: surgery (n = 242), radiotherapy (n = 547), and two chemotherapy groups, cumulative cisplatin dose < or = 850 mg (n = 402) and cumulative cisplatin dose more than 850 mg (n = 98). A control group consisted of healthy males from the Tromsø Population Study (n = 2,847).

RESULTS

At diagnosis, age-adjusted regression analyses showed no differences between the treatment groups for any variables. After a median follow-up time of 11.2 years, age-adjusted SBP and DBP were significantly higher for both chemotherapy groups compared with the surgery group. Chemotherapy-treated patients had increased odds for hypertension at follow-up compared with the surgery group, and the odds were highest for the cisplatin more than 850 mg group (odds ratio = 2.4; 95% CI, 1.4 to 4.0). The cisplatin more than 850 mg group had a significantly higher 10-year BMI increase and a higher prevalence of obesity at follow-up than the surgery group. Compared with healthy controls, chemotherapy-treated patients had, at follow-up, increased SBP, increased DBP, excessive BMI increase, and a higher prevalence of hypertension.

CONCLUSION

Five to 20 years after therapy, cured TC patients treated with cisplatin-based chemotherapy had significantly higher levels of blood pressure, a higher prevalence of hypertension, and an excessive weight gain compared with patients treated with other modalities and compared with healthy controls.

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.

The Metabolic Syndrome and Disturbances in Hormone Levels in Long-Term Survivors of Disseminated Testicular Cancer

Purpose

The metabolic syndrome may be an important risk factor for cardiovascular disease in long-term survivors of testicular cancer (TC). We investigated the associations between hormone levels and the metabolic syndrome in these men.

Patients and Methods

We included TC patients cured by orchidectomy and cisplatin-based chemotherapy, stage I TC patients after orchidectomy only, and healthy men of comparable age. Presence of the metabolic syndrome was determined using guidelines from the National Cholesterol Education Program Adult Treatment Panel III. Thyroid-stimulating hormone, follicle-stimulating hormone (FSH), inhibin B, luteinizing hormone (LH), total testosterone, sex-hormone–binding globulin, free testosterone, estradiol, dehydroepiandrosterone sulfate, and insulin-like growth factor 1 were determined in blood. Cortisol metabolite excretion was measured in urine.

Results

Eighty-six chemotherapy patients (median follow-up, 7 years) were compared with 44 stage I patients and 47 controls. LH and FSH were higher, and inhibin B and total and free testosterone were lower in chemotherapy patients than controls. Adrenal and thyroid hormone production were unaffected. Chemotherapy patients with the metabolic syndrome (n = 22; 26%) had a higher body mass index (BMI) pretreatment, a larger BMI increase during follow-up, lower total testosterone, and higher urinary cortisol metabolite excretion than those patients without the metabolic syndrome. BMI and insulin were associated with the metabolic syndrome, while total testosterone and urinary cortisol metabolite excretion were associated with BMI.

Conclusion

We found gonadal dysfunction, but normal adrenal and thyroid function. Through its association with BMI, testosterone may play a role in the development of the metabolic syndrome in long-term TC survivors.

Left ventricular and cardiac autonomic function in survivors of testicular cancer

BACKGROUND

Following cisplatin-based chemotherapy, survivors of testicular cancer have a high prevalence of cardiovascular risk factors and an increased risk of cardiovascular disease. Cardiac function has not been extensively studied and no comparisons have been made with men from the general population.

DESIGN

Left ventricular and cardiac autonomic function were evaluated in chemotherapy-treated testicular cancer patients, in stage I patients after orchidectomy only, and in healthy men using Doppler echocardiography [wall motion score index, peak early (E) and atrial filling (A) velocities across the mitral valve, E/A-ratio, isovolumetric relaxation time, and deceleration time of the early peak flow] and measurements of N-terminal pro-brain natriuretic peptide and baroreflex sensitivity. Furthermore, 24-h ambulatory blood pressure was measured.

RESULTS

Ninety chemotherapy-treated patients (median age 37 years, range 20-65; median follow up of 7 years, range 3-13) were compared with 44 stage I patients (median age 36 years, range 24-63) and 47 healthy controls (median age 37 years, range 22-55). Wall motion score index was less than 1.5 in all participants. Chemotherapy-treated patients had a higher peak A-wave and a lower E/A-ratio than stage I patients and controls. Isovolumetric relaxation and deceleration times did not differ between groups. Age, 24-h diastolic blood pressure and treatment with chemotherapy were significantly associated with E/A-ratio. Natriuretic peptide levels were normal. Baroreflex sensitivity was similar in the three groups.

CONCLUSIONS

Chemotherapy-treated testicular cancer survivors have a lower E/A-ratio than healthy subjects from the general population, which may indicate impaired relaxation of the left ventricle and reflect the high prevalence of cardiovascular risk factors previously reported in these men.

Self‐reported health and use of health care services in long‐term cancer survivors

Owing to an increasing number of long-term cancer survivors, the use of health care services and somatic health problems were compared between cancer survivors and a noncancer population. Data from the Nord-Trondelag Health Survey 2 (HUNT 2, 1995-1997) was merged with the Cancer Registry of Norway. Six cancer subgroups were constructed with diagnosis 5 years prior HUNT 2: testicular cancer (n= 59), colorectal cancer (n= 175), prostate cancer (n= 87), breast cancer (n= 258), gynaecological cancer (n= 153) and lymphoma/leukaemia (n= 83). For each cancer survivor 3 matched noncancer controls were selected from the HUNT 2 survey. The prevalence of common health problems, use of health care services and unfavourably life style parameters were compared between the 2 groups. Cancer survivors used health care services and received social welfare benefits more often than the controls. There was an increased risk of perceiving poor health after a history of cancer. Common health problems and/or unfavourable life style parameters could not explain poor health or the increased use of health care services among cancer survivors. Further studies are needed to investigate the reasons for increased use of health care services and perceived poor health in cancer survivors.

Increased mortality rates in young and middle-aged patients with malignant germ cell tumours

Cisplatin-based chemotherapy of malignant germ cell tumours (MGCT) has been reported to increase the risk of cardiovascular morbidity. A high incidence of second nongerm cell malignancies is well documented in MGCT survivors. The death risk due to these conditions is, however, more unknown in MGCT patients. Standard mortality rates (SMRs) were established in 3378 Norwegian MGCT patients treated from 1962 to 1997 aged ⩽55 years. The patients represented three principal treatment strategies: 1962/1969 (period 1): radiotherapy only; 1970/1979 (period 2): radiotherapy with or without noncisplatin-containing chemotherapy; 1980/1997 (period 3): surgery only or radiotherapy or cisplatin-based chemotherapy. Patients were censored when they reached the age of 60 years. Patients not dying from MGCT displayed significantly increased SMRs for respectively diseases of the circulatory system (SMR: 1.2, 95% confidence interval (CI): 1.0–1.5), benign gastrointestinal disorders (SMR: 2.1, 95% CI: 1.1–3.5) and nongerm cell malignancies (SMR: 2.0, 95% CI: 1.7–2.4). The SMRs for diseases of the circulatory system were similar in the three observation periods, whereas the highest SMR for benign gastrointestinal disorders was observed in patients from period 2. The risk of dying from a nongerm cell malignancy was increased both in periods 2 and 3. In conclusion, although the overall SMR for diseases of the circulatory system is increased in MCGT survivors, the introduction of cisplatin-based chemotherapy into the treatment of MGCT has so far not resulted in increased death rates due to these conditions. Patients with MGCT have a significantly increased relative death risk due to a second nongerm cell cancer, even after the introduction of modern treatment principles with overall reduction of radiotherapy. The increased death risk due to benign gastrointestinal disorders, probably related to radiotherapy, requires future in-depth analysis.

Microalbuminuria, decreased fibrinolysis, and inflammation as early signs of atherosclerosis in long-term survivors of disseminated testicular cancer

Testicular cancer patients have an increased risk for coronary artery disease more than ten years after cisplatin-based chemotherapy. We investigated whether vascular changes, including endothelial dysfunction, are present earlier. Ninety chemotherapy-treated testicular cancer patients (median follow-up of seven years) were compared with 44 patients after orchidectomy only and 47 healthy men. Microalbuminuria was present in 10 (12%) chemotherapy patients, one stage I patient and none of the controls. Chemotherapy patients had higher levels of fibrinogen, C-reactive protein (hs-CRP), von Willebrand factor (vWF), plasminogen activator inhibitor (PAI-1), and tissue-type plasminogen activator (t-PA). Chemotherapy patients with elevated PAI-1 (25/90) showed clustering of cardiovascular risk factors resembling the metabolic syndrome. In conclusion, cured testicular cancer patients showed a high prevalence of microalbuminuria and increased plasma levels of endothelial and inflammatory marker proteins, which might progress to more severe endothelial dysfunction and overt atherosclerosis.

Gonadal hormones in long-term survivors 10 years after treatment for unilateral testicular cancer

OBJECTIVE

To investigate whether unilaterally orchiectomised testicular cancer survivors (TCSs) are more likely to display reduced Leydig cell function than healthy males.

METHODS

A national multi-centre survey of 1235 TCSs was performed in 1998-2000 (mean age: 44 years) treated between 1980 and 1994 (mean follow-up: 11 years). Serum hormone analyses were performed on 1183 TCSs, as 52 TCSs used androgen replacement (AR). TCSs were allocated to four treatment groups: Surgery only (251); Radiotherapy only (515); Chemotherapy 1, cisplatin </=850 mg (373); Chemotherapy 2, cisplatin >850 mg (96). The Controls were represented by 200 healthy blue-collar workers (mean age: 44 years). LH >12 IU/l and testosterone <8 nmol/l and the use of AR indicated hypogonadism.

RESULTS

Serum testosterone was similar in TCSs and Controls (16.9 vs.17.1 nmol/l), but TCSs had higher age-adjusted LH levels than the Controls (5.2 vs. 3.5 IU/l). LH increased with treatment intensity, but was elevated even in TCSs treated with surgery only. The age-adjusted odds ratio of hypogonadism was 3.8 (95%CI: 2.0-7.3) in TCSs, and increased with treatment intensity.

CONCLUSION

TCSs are at risk to develop pre-mature reduced Leydig cell function and hypogonadism. They may therefore be predisposed for the syndrome of androgen deficiency of aging males (ADAM).

The level of physical activity in long-term survivors of testicular cancer

The aim of this study was to estimate the level of physical activity (LPA) in a large cohort of testicular cancer survivors (TCSs) and compare these results with observations from men in the same age range in the general population (GenPop). We also wanted to identify parameters that influenced physical activity. The study populations consisted of 1276 TCSs treated with surgery, radiotherapy or chemotherapy with or without surgery (mean observation time was 12 years), and 20391 male inhabitants from a Norwegian county (GenPop). All completed a question investigating two sub-levels of physical activity. The logistic regression analysis adjusting for different covariates, showed significantly more physically active men among the TCSs compared with the GenPop (43 versus 37%) (adjusted odds ratio (aOR)=1.32 (95% Confidence Interval (CI) 1.10-1.58)). The results indicate that the experience of testicular cancer increases rather than reduces the LPA in TCSs, independent of treatment given.