Life expectancy of colon, breast, and testicular cancer patients: an analysis of US-SEER population-based data

Estimating cure and risk of death from other causes of cancer patients: EUROCARE-6 data on head & neck, colorectal, and breast cancers

BACKGROUND

To estimate net survival and cancer cure fraction (CF), i.e. the proportion of patients no longer at risk of dying from cancer progression/relapse, a clear distinction needs to be made between mortality from cancer and from other causes. Conventionally, CF is estimated assuming no excess mortality compared to the general population.

METHODS

A new modelling approach, that corrects for patients' extra risk of dying (RR) from causes other than the diagnosed cancer, was considered to estimate both indicators. We analysed EUROCARE-6 data on head and neck (H&N), colorectal, and breast cancer patients aged 40-79, diagnosed from 1998 to 2002 and followed-up to 31/12/2014, provided by 65 European cancer registries.

FINDINGS

Young male H&N cancer patients have 4 times the risk of dying from other causes than their peers, this risk decreases with age to 1.6. Similar results were observed for female. We observed an absolute increase in CF of 30 % using the new model instead of the conventional one. For colorectal cancer, CF with the new model increased by a maximum of 3 % for older patients and the RR ranged from 1 to 1.2 for both sexes. CF of female breast cancer ranged from 73 % to 79 % using the new cure model, with RR between 1.2 and 1.4.

INTERPRETATION

Not considering a RR> 1 leads to underestimate the proportion of patients not bound to die of their diagnosed cancer. Estimates of cancer mortality risk have an important impact on patients' quality of life.

Associations of ultraprocessed food consumption with mortality among participants with a history of cancer: a prospective cohort analysis

BACKGROUND

Although high ultraprocessed food (UPF) consumption has been linked with increased mortality risk in the general population, whether UPFs harm participants with a history of cancer remains unclear.

OBJECTIVES

This study aimed to evaluate the association of UPF consumption with mortality among participants with a history of cancer.

METHODS

Prospective cohort analysis was conducted on 13,640 participants with a history of cancer from the UK Biobank. UPFs were defined by the Nova classification. UPF consumption was calculated as the weight proportion of UPFs in the total food consumption. Cox proportional hazard models were used to assess the association between UPF consumption and mortality among participants with a history of cancer.

RESULTS

The median UPF consumption was 29.25% (interquartile range [IQR]: 19.46%-40.62%) for males and 25.81% (IQR: 16.61%-36.35%) for females in the total diet among participants with a history of cancer. During a median follow-up of 10.77 years, 1611 deaths were documented. Multivariable-adjusted hazard ratios (95% confidence intervals) among participants in the highest quartile of UPF consumption relative to the lowest were 1.17 (1.02, 1.35) for all-cause mortality and 1.22 (1.03, 1.44) for cancer-related mortality.

CONCLUSIONS

Higher UPF consumption after the diagnosis among participants with a history of cancer is associated with higher risk of mortality.

Derivation and external validation of a simple risk score for predicting severe acute kidney injury after intravenous cisplatin: cohort study

OBJECTIVE

To develop and externally validate a prediction model for severe cisplatin associated acute kidney injury (CP-AKI).

DESIGN

Multicenter cohort study.

SETTING

Six geographically diverse major academic cancer centers across the US.

PARTICIPANTS

Adults (≥18 years) receiving their first dose of intravenous cisplatin, 2006-22.

MAIN OUTCOME MEASURES

The primary outcome was CP-AKI, defined as a twofold or greater increase in serum creatinine or kidney replacement therapy within 14 days of a first dose of intravenous cisplatin. Independent predictors of CP-AKI were identified using a multivariable logistic regression model, which was developed in a derivation cohort and tested in an external validation cohort. For the primary model, continuous variables were examined using restricted cubic splines. A simple risk model was also generated by converting the odds ratios from the primary model into risk points. Finally, a multivariable Cox model was used to examine the association between severity of CP-AKI and 90 day survival.

RESULTS

A total of 24 717 adults were included, with 11 766 in the derivation cohort (median age 59 (interquartile range (IQR) 50-67)) and 12 951 in the validation cohort (median age 60 (IQR 50-67)). The incidence of CP-AKI was 5.2% (608/11 766) in the derivation cohort and 3.3% (421/12 951) in the validation cohort. Each of the following factors were independently associated with CP-AKI in the derivation cohort: age, hypertension, diabetes mellitus, serum creatinine level, hemoglobin level, white blood cell count, platelet count, serum albumin level, serum magnesium level, and cisplatin dose. A simple risk score consisting of nine covariates was shown to predict a higher risk of CP-AKI in a monotonic fashion in both the derivation cohort and the validation cohort. Compared with patients in the lowest risk category, those in the highest risk category showed a 24.00-fold (95% confidence interval (CI) 13.49-fold to 42.78-fold) higher odds of CP-AKI in the derivation cohort and a 17.87-fold (10.56-fold to 29.60-fold) higher odds in the validation cohort. The primary model had a C statistic of 0.75 and showed better discrimination for CP-AKI than previously published models, the C statistics for which ranged from 0.60 to 0.68 (DeLong P<0.001 for each comparison). Greater severity of CP-AKI was monotonically associated with shorter 90 day survival (adjusted hazard ratio 4.63 (95% CI 3.56 to 6.02) for stage 3 CP-AKI versus no CP-AKI).

CONCLUSION

This study found that a simple risk score based on readily available variables from patients receiving intravenous cisplatin could predict the risk of severe CP-AKI, the occurrence of which is strongly associated with death.

Whole-grain intake in mid-life and healthy ageing in the Danish Diet, Cancer and Health cohort

PURPOSE

Growing elderly populations worldwide have sparked interest in factors promoting healthy aging. Diet and other lifestyle patterns are key factors for healthy ageing; however, evidence is sparse for specific dietary guidelines that are easily implemented in everyday life. Whole grains constitute specific dietary components with unexplored potential in healthy ageing.

METHODS

We applied an illness-death multistate model to assess the association between whole-grain intake and life expectancy, both with and without disease, over a 20-year period. Healthy ageing was defined as absence of cancer, ischemic heart disease, stroke, type 2 diabetes, asthma, chronic obstructive pulmonary disease, and dementia during follow-up.

RESULTS

Based on information from 22,606 men and 25,468 women in the Danish Diet, Cancer and Health cohort, followed for an average of 13.8 and 17.5 years, respectively, a doubling in whole-grain intake was associated with 0.43 (95% CI: 0.33-0.52) and 0.15 (0.06-0.24) additional years without disease for men and women, respectively. Comparing the highest and lowest quartiles of whole-grain intake, with a special emphasis on men, we found that those with the highest intake lived, on average, one year longer without disease compared to those with the lowest intake. Additionally, although a high intake of whole grains yielded longer life expectancy, the duration of living with disease was shorter.

CONCLUSION

Intake of whole grains in mid-life was associated with healthy ageing looking 20 years ahead.

Increase in the Life Expectancy of Patients with Cancer in the United States

BACKGROUND

Cancer is becoming more of a chronic disease due to improvements in treatment and early detection for multiple cancer sites. To gain insight on increased life expectancy due to these improvements, we quantified trends in the loss in expectation of life (LEL) due to a cancer diagnosis for six cancer sites from 1975 through 2018.

METHODS

We focused on patients diagnosed with female breast cancer, chronic myeloid leukemia (CML), colon and rectum cancer, diffuse large B-cell lymphoma (DLBCL), lung cancer, or melanoma between 1975 and 2018 from nine Surveillance, Epidemiology, and End Results cancer registries. Life expectancies for patients with cancer ages 50+ were modeled using flexible parametric survival models. LEL was calculated as the difference between general population life expectancy and life expectancy for patients with cancer.

RESULTS

Over 2 million patients were diagnosed with one of the six cancers between 1975 and 2018. Large increases in life expectancy were observed between 1990 and 2010 for female breast, DLBCL, and CML. Patients with colon and rectum cancer and melanoma had more gradual improvements in life expectancy. Lung cancer LEL only began decreasing after 2005. Increases in life expectancy corresponded with decreases in LEL for patients with cancer.

CONCLUSIONS

The reported gains in life expectancy largely correspond to progress in the screening, management, and treatment of these six cancers since 1975.

IMPACT

LEL provides an important public health perspective on how improvements in treatment and early detection and their impacts on survival translate into changes in cancer patients' life expectancy.

Dose-response association between cardiovascular health and mortality in cancer survivors

BACKGROUND

There is little knowledge on the dose-response association between cardiovascular health (CVH) and risk of all-cause, cardiovascular disease (CVD) and cancer deaths among cancer survivors.

AIMS

We aimed to examine the dose-response association of CVH with all-cause, CVD, and cancer mortality.

METHODS

A total of 1701 US adult cancer survivors were followed-up during a median of 7.3 (IQR 4.0-10.2) years from 2007 to 2018 through the National Health and Nutrition Examination Survey (NHANES). We used the American Heart Association´s (AHA) Life´s Essential 8 (LE8) as a proxy for CVH.

RESULTS

Restricted cubic spline models indicated a close to inverse linear shape for the dose-response association between LE8 score and all-cause mortality with significant risk reductions within the range between 61.25 (Hazard ratio [HR]: 0.76, 95% CI, 0.59-0.98) and 100 points (HR: 0.28, 95%CI, 0.12-0.62), and a curvilinear shape for the dose-response association between LE8 score and CVD deaths with significant risk reductions within the range between 50.25 (HR: 0.72, 95% CI, 0.52-0.99) and 90.25 points (HR: 0.15, 95%CI, 0.02-0.98). No significant dose-response association was observed between LE8 and cancer deaths.

CONCLUSIONS

Our study showed a close to inverse relationship between higher LE8 and risk of death from all cause, an inverse curvilinear relationship between higher LE8 and the risk for CVD death, and a non-significant association between higher LE8 and the risk of cancer death among US adult cancer survivors, which may translate to a substantial number of annual averted deaths and thus important public health implications.

Joint association of sedentary behavior and vitamin D status with mortality among cancer survivors

BACKGROUND

Sedentary behavior and vitamin D deficiency are independent risk factors for mortality in cancer survivors, but their joint association with mortality has not been investigated.

METHODS

We analyzed data from 2914 cancer survivors who participated in the National Health and Nutrition Examination Survey (2007-2018) and followed up with them until December 31, 2019. Sedentary behavior was assessed by self-reported daily hours of sitting, and vitamin D status was measured by serum total 25-hydroxyvitamin D (25(OH)D) levels.

RESULTS

Among 2914 cancer survivors, vitamin D deficiency was more prevalent in those with prolonged daily sitting time. During up to 13.2 years (median, 5.6 years) of follow-up, there were 676 deaths (cancer, 226; cardiovascular disease, 142; other causes, 308). The prolonged sitting time was associated with a higher risk of all-cause and noncancer mortality, and vitamin D deficiency was associated with a higher risk of all-cause and cancer mortality. Furthermore, cancer survivors with both prolonged sitting time (≥ 6 h/day) and vitamin D deficiency had a significantly higher risk of all-cause (HR, 2.05; 95% CI: 1.54-2.72), cancer (HR, 2.33; 95% CI, 1.47-3.70), and noncancer mortality (HR, 1.91; 95% CI, 1.33-2.74) than those with neither risk factor after adjustment for potential confounders.

CONCLUSIONS

In a nationally representative sample of U.S. cancer survivors, the joint presence of sedentary behavior and vitamin D deficiency was significantly associated with an increased risk of all-cause and cancer-specific mortality.

Special Issue "Novel Anti-Proliferative Agents"

Cancer is a disease that can affect any organ and spread to other nearby or distant organs [...].

Conditional survival of stage III non-seminoma testis cancer patients

PURPOSE

In many primaries other than non-seminoma testis cancer, the risk of death due to cancer decreases with increasing disease-free interval duration after initial diagnosis and treatment. This effect is known as conditional survival and is relatively unexplored in stage III non-seminoma patients, where it may matter most in clinical decision-making. We examined the effect of disease-free interval duration on overall survival in stage III non-seminoma patients.

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results Database (2004-2018), stage III non-seminoma patients were identified. Multivariable Cox regression analyses and conditional survival models were applied.

RESULTS

Of 2,092 surgically treated stage III non-seminoma patients, 385 (18%) exhibited good vs. 558 (27%) intermediate vs. 1,149 (55%) poor prognosis. In multivariable Cox regression models, poor prognosis group independently predicted overall mortality (HR 3.3, P < 0.001). In conditional survival analyses based on 36 months' disease-free interval duration, 5-year overall survival estimates were as follows: good prognosis patients 96 vs. 89% at initial diagnosis without accounting for disease-free interval duration (Δ=+7); intermediate prognosis patients 94 vs. 85% at initial diagnosis without accounting for disease-free interval duration (Δ=+9); poor prognosis patients 94 vs. 65% at initial diagnosis without accounting for disease-free interval duration (Δ=+29).

CONCLUSIONS

Conditional survival estimates based on 36 months' disease-free interval duration provide a more accurate and more optimistic outlook for stage III non-seminoma patients than predictions defined at initial diagnosis, without accounting for disease-free interval duration.

Association of dietary total antioxidant capacity and its distribution across three meals with all-cause, cancer, and non-cancer mortality among cancer survivors: the US National Health and Nutrition Examination Survey, 1999-2018

The effect of the antioxidant capacity of diet and its distribution across three meals on mortality risk among cancer patients remains unexplored. We aimed to prospectively investigate the association of dietary total antioxidant capacity (DAC) and its distribution across three meals with all-cause, cancer, and noncancer mortality among cancer survivors. We included 5,009 patients with cancer from the National Health and Nutrition Examination Survey conducted between 1999 and 2018. The adjusted hazard ratio (aHR) was estimated using the survey-weighted Cox proportional hazards model. During a median follow-up of 7.9 years, 1811 deaths, including 575 cancer-related deaths, were recorded. Among cancer survivors, compared with participants in the lowest quartile of total DAC from three meals, those in the highest quartile had a 24% decreased risk of noncancer mortality (aHR = 0.76, 95% confidence interval [CI]: 0.60-0.92), but not of all-cause and cancer mortality (each p trend >0.1). However, this association became insignificant for total DAC after excluding dinner DAC. In addition, higher dinner DAC rather than breakfast or lunch DAC was associated with a 21% lower risk of all-cause mortality (aHR = 0.79, 95% CI: 0.65-0.98) and 28% lower risk of noncancer mortality (aHR = 0.72, 95% CI: 0.57-0.90). Similar associations were found for ΔDAC (dinner DAC - breakfast DAC) with noncancer mortality (aHR = 0.56, 95% CI: 0.38-0.83), but DAC was not associated with cancer mortality (p trend >0.3). Among cancer survivors, total DAC from three meals was associated with reduced noncancer mortality, with the primary effect attributable to increased DAC intake from dinner. Our findings emphasize that DAC consumption from dinner should be advocated to reduce mortality risk in cancer survivors.

Use of Systemic Therapies for Treatment of Psoriasis in Patients with a History of Treated Solid Tumours: Inference-Based Guidance from a Multidisciplinary Expert Panel

BACKGROUND

Patients with treated solid tumours (TSTs) are a highly heterogeneous population at an increased risk for malignancy compared with the general population. When treating psoriasis in patients with a history of TSTs, clinicians are concerned about the immunosuppressive nature of psoriasis therapies, the possibility of augmenting cancer recurrence/progression, and infectious complications. No direct, high-level evidence exists to address these concerns.

OBJECTIVES

We aim to provide a structured framework supporting healthcare professional and patient discussions on the risks and benefits of systemic psoriasis therapy in patients with previously TSTs. Our goal was to address the clinically important question, "In patients with TSTs, does therapy with systemic agents used for psoriasis increase the risk of malignancy or malignancy recurrence?"

METHODS

We implemented an inference-based approach relying on indirect evidence when direct clinical trial and real-world data were absent. We reviewed indirect evidence supporting inferences on the status of immune function in patients with TSTs. Recommendations on systemic psoriasis therapies in patients with TSTs were derived using an inferential heuristic.

RESULTS

We identified five indirect indicators of iatrogenic immunosuppression informed by largely independent bodies of evidence: (1) overall survival, (2) rate of malignancies with psoriasis and systemic psoriasis therapies, (3) rate of infections with psoriasis and systemic psoriasis therapies, (4) common disease biochemical pathways for solid tumours and systemic psoriasis therapies, and (5) solid organ transplant outcomes. On the basis of review of the totality of this data, we provided inference-based conclusions and ascribed level of support for each statement.

CONCLUSIONS

Prior to considering new therapies for psoriasis, an understanding of cancer prognosis should be addressed. Patients with TSTs and a good cancer prognosis will have similar outcomes to non-TST patients when treated with systemic psoriasis therapies. For patients with TSTs and a poor cancer prognosis, the quality-of-life benefits of treating psoriasis may outweigh the theoretical risks.

A new cure model that corrects for increased risk of non-cancer death: analysis of reliability and robustness, and application to real-life data

BACKGROUND

Non-cancer mortality in cancer patients may be higher than overall mortality in the general population due to a combination of factors, such as long-term adverse effects of treatments, and genetic, environmental or lifestyle-related factors. If so, conventional indicators may underestimate net survival and cure fraction. Our aim was to propose and evaluate a mixture cure survival model that takes into account the increased risk of non-cancer death for cancer patients.

METHODS

We assessed the performance of a corrected mixture cure survival model derived from a conventional mixture cure model to estimate the cure fraction, the survival of uncured patients, and the increased risk of non-cancer death in two settings of net survival estimation, grouped life-table data and individual patients' data. We measured the model's performance in terms of bias, standard deviation of the estimates and coverage rate, using an extensive simulation study. This study included reliability assessments through violation of some of the model's assumptions. We also applied the models to colon cancer data from the FRANCIM network.

RESULTS

When the assumptions were satisfied, the corrected cure model provided unbiased estimates of parameters expressing the increased risk of non-cancer death, the cure fraction, and net survival in uncured patients. No major difference was found when the model was applied to individual or grouped data. The absolute bias was < 1% for all parameters, while coverage ranged from 89 to 97%. When some of the assumptions were violated, parameter estimates appeared more robust when obtained from grouped than from individual data. As expected, the uncorrected cure model performed poorly and underestimated net survival and cure fractions in the simulation study. When applied to colon cancer real-life data, cure fractions estimated using the proposed model were higher than those in the conventional model, e.g. 5% higher in males at age 60 (57% vs. 52%).

CONCLUSIONS

The present analysis supports the use of the corrected mixture cure model, with the inclusion of increased risk of non-cancer death for cancer patients to provide better estimates of indicators based on cancer survival. These are important to public health decision-making; they improve patients' awareness and facilitate their return to normal life.

Measuring population-level cure patterns for cancer patients in the United States

While the life expectancy of cancer survivors has substantially improved over time in the United States, the extent to which cancer patients are cured is not known. Population-level cure patterns are important indicators to quantify cancer survivorships. This population-based cohort study included 8978,721 cancer patients registered in the Surveillance, Epidemiology and End Results (SEER) databases between 1975 and 2018. The primary outcome was cure fractions. Five-year cure probability, time to cure and median survival time of uncured cases were also assessed. All four measures were calculated using flexible parametric models, according to 46 cancer sites, three summary stages, individual age and calendar year at diagnosis. In 2018, cure fractions ranged from 2.7% for distant liver cancer to 100.0% for localized/regional prostate cancer. Localized cancer had the highest cure fraction, followed by regional cancer and distant cancer. Except for localized breast cancer, older patients generally had lower cure fractions. There were 38 cancer site and stage combinations (31.2%) that achieved 95% of cure within 5 years. Median survival time of the uncured cases ranged from 0.3 years for distant liver cancer to 10.9 years for localized urinary bladder cancer. A total of 117 cancer site and stage combinations (93.6%) had increased cure fraction over time. A considerable proportion of cancer patients were cured at the population-level, and the cure patterns varied substantially across cancer site, stage and age at diagnosis. Increases in cure fractions over time likely reflected advances in cancer treatment and early detection.

Biomarkers of disease recurrence in stage I testicular germ cell tumours

Stage I testicular cancer is a disease restricted to the testicle. After orchiectomy, patients are considered to be without disease; however, the tumour is prone to relapse in ~4-50% of patients. Current predictive markers of relapse, which are tumour size and invasion to rete testis (in seminoma) or lymphovascular invasion (in non-seminoma), have limited clinical utility and are unable to correctly predict relapse in a substantial proportion of patients. Adjuvant therapeutic strategies based on available biomarkers can lead to overtreatment of 50-85% of patients. Discovery and implementation of novel biomarkers into treatment decision making will help to reduce the burden of adjuvant treatments and improve patient selection for adjuvant therapy.

Associations of Body Fat Distribution and Cardiometabolic Risk of Testicular Cancer Survivors after Cisplatin-Based Chemotherapy

Background

It is unknown how body fat distribution modulates the cardiometabolic risk of testicular cancer survivors (TCSs) after cisplatin-based chemotherapy.

Methods

For 455 patients enrolled in The Platinum Study at Memorial Sloan Kettering Cancer Center, visceral (VAT) and subcutaneous (SAT) adipose tissue was quantified on pre-chemotherapy CT. VAT/SAT ratio was calculated as a quantitative measure of central adiposity. Endpoints were incidence of new post-chemotherapy cardiometabolic disease (new antihypertensive, lipid-lowering, or diabetes medication), and post-chemotherapy Framingham risk scores. Cox models and linear regression with interaction terms were applied. Post-chemotherapy body fat distribution was analyzed in 108 patients. All statistical tests were 2-sided.

Results

Baseline median age was 31 years (IQR = 26, 39), BMI 26 kg/m2 (IQR: 24, 29), and VAT/SAT ratio 0.49 (IQR: 0.31, 0.75). Median follow-up was 26 months (IQR: 16, 59). Higher pre-chemotherapy VAT/SAT ratios inferred a higher likelihood of new cardiometabolic disease among patients with BMI ≥30 kg/m2 (age-adjusted HR = 3.14, 95% CI = 1.02–9.71, p = 0.047), but not other BMI groups. Pre-chemotherapy VAT/SAT ratio was associated with post-chemotherapy Framingham risk scores in univariate regression analysis (exp(β)-estimate: 2.10, 95% CI: 1.84, 2.39, p &lt; 0.001); in a multivariate model, this association was stronger in younger versus older individuals. BMI increased in most patients after chemotherapy and correlated with increases in VAT/SAT (Spearman r = 0.39; p &lt; 0.001).

Conclusions

In TCSs, central adiposity is associated with increased cardiometabolic risk after cisplatin-based chemotherapy, particularly in obese or young men. Weight gain after chemotherapy occurs preferentially in the visceral compartment, providing insight into the pathogenesis of cardiovascular disease in this population.

Ototoxicity After Cisplatin-Based Chemotherapy: Factors Associated With Discrepancies Between Patient-Reported Outcomes and Audiometric Assessments

OBJECTIVES

To provide new information on factors associated with discrepancies between patient-reported and audiometrically defined hearing loss (HL) in adult-onset cancer survivors after cisplatin-based chemotherapy (CBCT) and to comprehensively investigate risk factors associated with audiometrically defined HL.

DESIGN

A total of 1410 testicular cancer survivors (TCS) ≥6 months post-CBCT underwent comprehensive audiometric assessments (0.25 to 12 kHz) and completed questionnaires. HL severity was defined using American Speech-Language-Hearing Association criteria. Multivariable multinomial regression identified factors associated with discrepancies between patient-reported and audiometrically defined HL and multivariable ordinal regression evaluated factors associated with the latter.

RESULTS

Overall, 34.8% of TCS self-reported HL. Among TCS without tinnitus, those with audiometrically defined HL at only extended high frequencies (EHFs) (10 to 12 kHz) (17.8%) or at both EHFs and standard frequencies (0.25 to 8 kHz) (23.4%) were significantly more likely to self-report HL than those with no audiometrically defined HL (8.1%) [odds ratio (OR) = 2.48; 95% confidence interval (CI), 1.31 to 4.68; and OR = 3.49; 95% CI, 1.89 to 6.44, respectively]. Older age (OR = 1.09; 95% CI, 1.07 to 1.11, p < 0.0001), absence of prior noise exposure (OR = 1.40; 95% CI, 1.06 to 1.84, p = 0.02), mixed/conductive HL (OR = 2.01; 95% CI, 1.34 to 3.02, p = 0.0007), no hearing aid use (OR = 5.64; 95% CI, 1.84 to 17.32, p = 0.003), and lower education (OR = 2.12; 95% CI, 1.23 to 3.67, p = 0.007 for high school or less education versus postgraduate education) were associated with greater underestimation of audiometrically defined HL severity, while tinnitus was associated with greater overestimation (OR = 4.65; 95% CI, 2.64 to 8.20 for a little tinnitus, OR = 5.87; 95% CI, 2.65 to 13.04 for quite a bit tinnitus, and OR = 10.57; 95% CI, 4.91 to 22.79 for very much tinnitus p < 0.0001). Older age (OR = 1.13; 95% CI, 1.12 to 1.15, p < 0.0001), cumulative cisplatin dose (>300 mg/m2, OR = 1.47; 95% CI, 1.21 to 1.80, p = 0.0001), and hypertension (OR = 1.80; 95% CI, 1.28 to 2.52, p = 0.0007) were associated with greater American Speech-Language-Hearing Association-defined HL severity, whereas postgraduate education (OR = 0.58; 95% CI, 0.40 to 0.85, p = 0.005) was associated with less severe HL.

CONCLUSIONS

Discrepancies between patient-reported and audiometrically defined HL after CBCT are due to several factors. For survivors who self-report HL but have normal audiometric findings at standard frequencies, referral to an audiologist for additional testing and inclusion of EHFs in audiometric assessments should be considered.

Association of Daily Sitting Time and Leisure-Time Physical Activity With Survival Among US Cancer Survivors

IMPORTANCE

Sedentary behaviors, particularly prolonged sitting and lack of physical activity, may influence survival after cancer.

OBJECTIVE

To examine the independent and joint associations of daily sitting time and leisure-time physical activity with mortality outcomes among cancer survivors.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort of a nationally representative sample of cancer survivors, age 40 years or older (n = 1535; weighted population, 14 002 666), from the US National Health and Nutrition Examination Survey from 2007 to 2014. Participants were linked to mortality data from their interview and physical examination date through December 31, 2015. Daily sitting time and leisure-time physical activity (LTPA) were self-reported using the Global Physical Activity Questionnaire. Data analyses were performed from January 1 to May 1, 2021.

MAIN OUTCOMES AND MEASURES

All-cause, cancer-specific, and noncancer mortality.

RESULTS

Among 1535 cancer survivors (mean [SE] age, 65.1 [0.4] years; 828 [60.1%] females; 945 [83.1%] non-Hispanic White individuals), 950 (56.8%) reported LTPA of 0 minutes per week (min/wk) during the previous week (inactive); 226 (15.6%) reported LTPA of less than 150 min/wk (insufficiently active); 359 (27.6%) reported LTPA of 150 min/wk or more (active); 553 (35.4%) reported sitting for 6 to 8 hours per day (h/d); and 328 (24.9%) reported sitting for more than 8 h/d. Of note, 574 (35.8%) cancer survivors reported no LTPA with concurrent sitting of more than 6 h/d. During the follow-up period of up to 9 years (median, 4.5 years; 6980 person-years), there were 293 deaths (cancer, 114; heart diseases, 41; other causes, 138). Multivariable models showed that being physically active was associated with lower risks of all-cause (hazard ratio [HR], 0.34; 95% CI, 0.20-0.60) and cancer-specific (HR, 0.32; 95% CI, 0.15-0.70) mortality compared with inactivity. Sitting more than 8 h/d was associated with higher risks of all-cause (HR, 1.81; 95% CI, 1.05-3.14) and cancer-specific (HR, 2.27; 95% CI, 1.08-4.79) mortality compared with those sitting less than 4 h/d. In the joint analyses, prolonged sitting was associated with an increased risk of death among cancer survivors who were not sufficiently active. Specifically, inactive and insufficiently active survivors reported sitting more than 8 h/d had the highest overall (HR, 5.38; 95% CI, 2.99-9.67) and cancer-specific (HR, 4.71; 95% CI, 1.60-13.9) mortality risks.

CONCLUSIONS AND RELEVANCE

In this cohort study of a nationally representative sample of US cancer survivors, the combination of prolonged sitting with lack of physical activity was highly prevalent and was associated with the highest risks of death from all causes and cancer.

Life expectancy and cancer survival in Oncosalud: outcomes over a 15-year period in a Peruvian private institution

Background

There is a large gap in the data on cancer outcomes in Latin America, making it difficult to establish adequate cancer control policies in the region. The aim of our study was to describe the survival, life expectancy estimates and life expectancy changes over time for a large cohort of Peruvian patients insured with Oncosalud, a private healthcare system.

Patients and methods

We evaluated a retrospective cohort of patients diagnosed between 2000 and 2015 in Oncosalud (Lima-Peru). Cases included colon, rectum, stomach, bladder, breast, prostate and non-melanoma skin cancers. Survival was evaluated with the Kaplan–Meier methodology. The standard period life table was used to estimate the excess mortality risks of patients in our cohort compared to the population covered by the Peruvian Superintendence of Banks, Insurance Companies and Pension Funds (SBS). The years of life lost was estimated based on SBS population, matching patients by age and sex.

Results

A large cohort of 7,687 Peruvian cancer patients managed in a 15-year period was eligible. If patients survive 5 years after a cancer diagnosis, life expectancy tends to be close to that of a population without cancer. The number of years of life lost at diagnosis was higher at the youngest ages, steadily decreasing thereafter. During the first years after cancer diagnosis, young patients face a much higher loss in life expectancy than older ones. Patients suffering from colon, rectum, stomach and bladder cancer are the most affected by the years of life lost.

Conclusion

In cancer patients surviving ≥ 5 years, life expectancy becomes similar to that observed in a population with similar socioeconomic characteristics. The estimated survival rate in our cohort is higher than that reported by public cancer registries in Peru. This could be explained by the different socio-economic background and access to specialised cancer care.

Cost-Effectiveness of Nutrient Supplementation in Cancer Survivors

Cancer patients are at risk for malnutrition; the aim of this study was to provide a cost-effectiveness analysis of dietary supplementation in cancer survivors. We estimated prevalence of supplementation, hospitalization rates, quality of life (QOL), cost of care and mortality among cancer survivors. We built a decision analytic model to simulate life-long costs of health care and supplementation and QOL among cancer survivors with and without supplementation. Cost of supplements was derived from national pharmacy databases including single- and multivitamin formularies. One-way and probabilistic sensitivity analysis were performed to evaluate the robustness of the incremental cost-effectiveness ratio (ICER) to changes in supplementation costs and duration. The study cohort represented the national cancer survivor population (average age 61 years, 85% white, 52% male, and 94% insured). Hospitalization rates for supplement users and non-users were 12% and 21%, respectively. The cost of hospitalization was $4030. Supplementation was associated with an additional 0.48 QALYs (10.26 vs. 9.78) at the incremental cost of $2094 ($236,933 vs. $234,839) over the remaining lifetime of survivors (on average 13 years). Adequate nutrition provides a cost-effective strategy to achieving potentially optimum health. Further studies are needed to determine the effects of specific nutrient doses and supplementation on long-term outcomes per cancer type.

The Impasse on Overall Survival in Oncology Reimbursement Decision-Making: How Can We Resolve This?

Mature overall survival (OS) data are often unavailable at the time of regulatory and reimbursement decisions for a new cancer treatment. For patients with early-stage cancers treated with potentially curative treatments, demonstrating an OS benefit may take years and may be confounded by subsequent lines of therapy or crossover to the investigational treatment. For patients with advanced-stage cancers, mature OS data may be available but difficult to interpret for similar reasons. There are strong opinions about approval and reimbursement in the absence of mature OS data, with concerns over delay in patient access set against concerns about uncertainty in long-term benefit. This position paper reflects our individual views as patient advocate, clinician or health economist on one aspect of this debate. We look at payer decisions in the absence of mature OS data, considering when and how non-OS trial outcomes could inform decision-making and how uncertainty can be addressed beyond the trial, supporting these views with evidence from the literature. We consider when it is reasonable for payers to expect or not expect mature OS data at the initial reimbursement decision (based on criteria such as cancer stage and treatment efficacy) acknowledging that there are settings in which mature OS data are expected. We propose flexible strategies for generating and appraising patient-relevant evidence, including context-relevant endpoints and quality of life measures, when survival rates are good and mature OS data are not expected. We note that fair reimbursement is important; this means valuing patient benefit as shown through prespecified endpoints and reappraising if there is ongoing uncertainty or failure to show a sustained benefit. We suggest that reimbursement systems continue to evolve to align with scientific advances, because innovation is only meaningful if readily accessible to patients. The proposed strategies have the potential to promote thorough assessment of potential benefit to patients and lead to timely access to effective medicines.

Association of healthy lifestyle score with all-cause mortality and life expectancy: a city-wide prospective cohort study of cancer survivors

BACKGROUND

Adherence to a healthy lifestyle could reduce the cancer mortality in the western population. We conducted a city-wide prospective study in China investigating the association of a healthy lifestyle score with all-cause mortality and the life expectancy in cancer survivors.

METHODS

This prospective cohort study included 46,120 surviving patients who were firstly diagnosed with cancer in Guangzhou. Five low-risk lifestyle factors including never smoking, never alcohol use, regular physical activity (≥ 2 h/week), sufficient sleep (≥ 6 h/day), and normal or high BMI (≥ 18.5 kg/m²) were assessed and a lifestyle score (0-5, a higher score indicates healthier lifestyle) was generated. Hazard ratios (HRs) of all-cause mortality and the life expectancy by levels of the lifestyle scores were estimated.

RESULTS

Of 46,120 cancer survivors registered from 2010 to 2017, during an average follow-up of 4.3 years (200,285 person-years), 15,209 deaths were recorded. Adjusted HRs for mortality in cancer survivors with lifestyle score of 0-2, versus 5, were 2.59 (95% confidence interval (CI): 2.03-3.30) in women, 1.91 (95%CI 1.77-2.05) in men, 2.28 (95%CI 2.03-2.55) in those aged <65 years, and 1.90 (95%CI 1.75, 2.05) in those aged ≥ 65 years. Life expectancy at age 55 for those with a score of 0-2 and 5 was 53.4 and 57.1 months, respectively. We also found that cancer survivors with healthy lifestyle scores of 5 showed 59.9 months of life expectancy on average, which was longer than those with a score of 0-2.

CONCLUSION

Adopting a healthy lifestyle was associated with a substantially lower risk of all-cause mortality and longer life expectancy in cancer survivors. Our findings should be useful for health education and health promotion in primary care and clinical practice.

Toll-like receptor 2 (TLR2) is a candidate prognostic factor in testicular germ cell tumors as well as an indicator of immune function in the tumor microenvironment

Testicular cancer is the most common malignant tumor in young men, and its incidence has increased in recent years. The tumor microenvironment (TME) plays a crucial role in the development and progression of tumors; however, the TME of testicular germ cell tumor (TGCT) is poorly understood. In this study, we downloaded information for 156 TGCT cases from The Cancer Genome Atlas (TCGA) database, used the ESTIMATE method to determine immune and stromal scores, and used CIBERSORT to calculate the proportion of tumor-infiltrating immune cells (TICs). The differentially expressed genes were subjected to a COX regression analysis and used for the construction of a protein–protein interaction (PPI) network. Toll-like receptor 2 (TLR2) was identified as a predictive marker by combining the results of the Cox regression analysis and PPI network. A survival analysis showed that TLR2 was positively correlated with TGCT survival. A gene set enrichment analysis indicated that genes in the high TLR2 expression group were enriched for cell adhesion molecules (CAMs) and the chemokine signaling pathway, and genes in the low TLR2 expression group were mainly enriched in the spliceosome. Regarding proportions of TICs, naive B cells and follicular helper T cells were negatively correlated with the expression of TLR2. This suggests that as TLR2 expression increases, the immunocompetence of the TME decreases. The expression of TLR2 may affect the prognosis of TGCT, suggesting that this locus can be used as a prognostic factor for TGCT.

Immunosurveillance of Cancer and Viral Infections with Regard to Alterations of Human NK Cells Originating from Lifestyle and Aging

Natural killer (NK) cells are cytotoxic immune cells with an innate capacity for eliminating cancer cells and virus- infected cells. NK cells are critical effector cells in the immunosurveillance of cancer and viral infections. Patients with low NK cell activity or NK cell deficiencies are predisposed to increased risks of cancer and severe viral infections. However, functional alterations of human NK cells are associated with lifestyles and aging. Personal lifestyles, such as cigarette smoking, alcohol consumption, stress, obesity, and aging are correlated with NK cell dysfunction, whereas adequate sleep, moderate exercise, forest bathing, and listening to music are associated with functional healthy NK cells. Therefore, adherence to a healthy lifestyle is essential and will be favorable for immunosurveillance of cancer and viral infections with healthy NK cells.

Temporal improvements noted in life expectancy of patients with colorectal cancer; a Dutch population-based study

OBJECTIVE

Specific survival estimates are needed for the increasing number of colorectal cancer (CRC) survivors. The aim of this population-based study was to determine conditional loss in expectation of life (LEL) due to CRC.

STUDY DESIGN AND SETTING

All surgically treated patients with CRC registered in the Netherlands Cancer Registry with stage I-III between 1990-2016, were included (N = 203,216). Estimates of conditional LEL were predicted using flexible parametric models and the total life years lost due to cancer were estimated.

RESULTS

LEL decreased with older age and patients with rectal cancer or higher disease stage had highest LEL. In 2010, LEL for sixty-year old male and female patients was 2 vs. 2, 4 vs. 4, and 7 vs. 8 years for colon cancer, and 2 vs. 2, 4 vs. 5 and 7 vs. 8 years for rectal cancer, respectively. Conditional LEL in patients with CRC decreased during follow-up. Patients with combined stage I-III colon and rectal cancer in 2010 lost an estimated 18,628 and 11,336 life years.

CONCLUSION

This study quantified the impact of CRC on patient's life expectancy, both on individual and population level and demonstrated temporal improvements in CRC survival. These results provide meaningful information that can be used during follow-up.

Treatment of clinical stage I non-seminoma

Germ cell cancers are the most common solid tumors among men between 15 and 40 years. Non-seminomatous germ cell tumors (NSGCTs) represent a unique and exclusive cohort of germ cell tumor patients. Non-seminoma can harbor different histologic components. The most commonly found histologies are embryonal cell cancer, teratoma, yolk sack tumor and choriocarcinoma, as well as teratocarcinoma and seminoma, in combination with non-seminomatous germ cell tumors histologic types. The clinical definition of stage I non-seminoma is the absence of metastatic lesions on imaging and normal tumor markers. The cure rate for clinical stage I NSGCT is 99% and this can be achieved by three therapeutic strategies: Active surveillance with treatment at the time of relapse, retroperitoneal lymph node dissection or adjuvant chemotherapy. The balancing of these various strategies should always be based on an individual risk profile of NGSCG patient depending on the lymphovascular invasion of the tumor.

m6A RNA methylation regulators play an important role in the prognosis of patients with testicular germ cell tumor

Background

N6-methyladenosine (m6A) is found to be associated with promoting tumorigenesis in different types of cancers, however, the function of m6A-related genes in testicular germ cell tumors (TGCT) development remains to be illuminated. This study aimed to investigated the prognostic value of m6A RNA methylation regulators in TGCT.

Methods

We collected TGCT patients’ information about clinicopathologic parameters and twenty-two m6A regulatory genes expression from The Cancer Genome Atlas (TCGA) database and Genotype-Tissue Expression (GTEx). We analyzed the differentially expressed m6A RNA methylation regulators between tumor tissues and normal tissues, as well as the correlation of m6A RNA methylation regulators. By using Cox univariate analysis, last absolute shrinkage and selection operator (LASSO) Cox regression algorithm and Cox multivariate proportional hazards regression analysis, a risk score was constructed based on a TCGA training cohort, and further verified in the TCGA testing cohort. Then, univariate and multivariate Cox regression analyses were used to evaluate the relationship between risk score and progression-free survival (PFS) in TGCT. Finally, the six-gene risk score was further verified by two gene expression profiles (GSE3218 and GSE10783) as an independent external validation cohort.

Results

Distinct expression patterns of m6A regulatory genes were identified between TGCT tissues and normal tissues in TCGA and GTEx datasets. To predict prognosis of TGCT patients, a risk score was calculated based on six selected m6A RNA methylation regulators (YTHDF1, RBM15, IGF2BP1, ZC3H13, METTL3, and FMR1). Additionally, we found significant differences between the high-risk and low-risk groups in serum marker study levels and histologic subtype. Univariate and multivariate analysis indicated that high risk score was associated with unfavorable PFS. Ultimately, the risk score was further verified by two gene expression profiles (GSE3218 and GSE10783).

Conclusions

Based on six selected m6A RNA methylation regulators, we developed a m6A methylation related risk score that can independently predict the prognosis of TGCT patients, and verify the prediction efficiency in TCGA and GEO datasets. Patients in high-risk group were associated with serum tumor marker study levels beyond the normal limits, non-seminoma, and unfavorable survival time. However, further prospective experiments should be carried out to verify our results.

Semen quality in non-Hodgkin lymphoma survivors: a monocentric retrospective study

STUDY QUESTION

How is semen quality affected by treatment in survivors of non-Hodgkin lymphoma (NHL)?

SUMMARY ANSWER

Before cancer treatment, most NHL subjects were normozoospermic and, while standard first-line treatments seemed compatible with post-treatment recovery after 18 months, salvage therapy followed by haematopoietic stem cell transplant caused permanent damage to spermatogenesis in many cases, with 66% azoospermic subjects in the long term.

WHAT IS KNOWN ALREADY

Testicular function has been widely investigated in relation to the most common malignancies in men of reproductive age, such as testicular cancer and Hodgkin lymphoma, but NHL has been somewhat under-investigated. The available reports generally show a post-treatment worsening of semen parameters in NHL survivors, but they involved small caseloads or a subgroup of broader caseloads, and their results are not comparable.

STUDY DESIGN, SIZE, DURATION

We conducted a retrospective analysis of 222 subjects who attended our University Hospital Sperm Bank between 2002 and 2017 for sperm cryopreservation after a diagnosis of NHL.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The study included 222 patients with NHL who underwent sperm cryopreservation before any antineoplastic treatment. Subjects with any comorbidity and/or other conditions interfering with sperm parameters were excluded. All patients underwent a careful medical history and physical examination at the time of sperm cryopreservation (T0) and had at least one follow-up visit at 6 (T6), 12 (T12), 18 (T18) and/or 24 months (T24) or more than 24 months (T > 24), with a median follow-up of 47.5 months (range 28-140 months). Fertility information was collected through the administration of a questionnaire.

MAIN RESULTS AND THE ROLE OF CHANCE

Pre-treatment, more than 80% of NHL patients were normozoospermic and in 15.9% of cases had already fathered a child. Aggressive lymphomas were associated with worse baseline semen volume and total sperm number compared to indolent subtypes (P < 0.05). Post-treatment analyses showed that standard first-line treatments alone had a more favourable outcome than intensified regimens for semen parameters, with total sperm number returning to near-baseline values at 18 months (T0: 195.0 ± 189.8 versus T18: 113.4 ± 103.1, P = 0.278), and a 7.7% prevalence of azoospermia at 2 years. In this subgroup receiving standard first-line treatments, radiotherapy of the pelvis versus other 'high' sites (mediastinum, latero-cervical and axillary lymph nodes, etc.) was associated with an increased risk of developing post-treatment azoospermia (odds ratio 4.29, 95% CI 1.81-10.14; P = 0.001). Two-thirds of subjects who had relapsed or had disease progression after first-line treatment and then underwent salvage treatment ± haematopoietic stem cell transplant became azoospermic. Fertility data were available for 176 patients: 15.9% already had at least one child prior to the NHL diagnosis and 12.5% (22 patients) desired children after treatment. Fourteen patients achieved fatherhood: 12 through natural conception and two following ART.

LIMITATIONS, REASONS FOR CAUTION

The main limitations of the study are the lack of data on blood hormones for evaluation of testicular function as a whole and the non-compliance of several patients in attending follow-up visits at all time points, resulting in a reduced sample size for the treatment subgroup analyses. Furthermore, despite a good fertility questionnaire response rate (>80%), the low number of NHL survivors actively seeking fatherhood limits the generalization of results.

WIDER IMPLICATIONS OF THE FINDINGS

The increased survival of NHL patients of reproductive age makes it essential to focus on the testicular toxicity of the treatment. Sperm cryopreservation must be suggested before any treatment. Two years after first-line treatments, sperm number showed signs of recovery: this finding is of the utmost importance for oncofertility counselling, as it indicates that only a standard first-line chemotherapy in many patients may be compatible with at least a partial spermatogenesis recovery in the long term. Nonetheless, it is expected that up to 30% of subjects will require treatment intensification, which could result in permanent testicular damage; in such cases the use of banked semen might represent the patient's best chance for future fertility.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by a grant from the Italian Ministry of Education and Research (MIUR-PRIN 2015-2015XSNA83-002) and the 'Sapienza' University of Rome, Faculty of Medicine. The authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

The insurability of innovative pharmaceutical cancer technologies

The scientific literature, including several papers published in the IJHPR, has raised the issue of the spiraling cost of cancer treatment, including that of cancer drugs and other technologies such as gene and cell therapies. In this perspective, we review three criteria for insurability and show that they may not be met.

First, the uncertain trends in the cost of innovative pharmaceutical and other cancer technologies make the maximum possible loss per event very difficult to predict and to manage in terms of insurer solvency. Second, the uncertainty of the price, the period that a drug or other cancer care technology will be administered and the number of individuals that will need the technology makes it difficult to predict future insurance premiums and whether they will be affordable to the target population. Third, public coverage needs to be consistent with societal values. However, pressure to limit public coverage will gradually increase as the possibilities of innovative pharmaceutical cancer technologies expand, thus transferring the burden onto commercial insurance. This is a phenomenon that is virtually impossible to predict accurately, but which will certainly undermine the status of health as a social good.

We conclude that the financial risk arising from the use of innovative pharmaceutical cancer technologies fails to meet the aforementioned criteria, thus raising questions as to the sustainability of commercial insurance for cancer treatment and suggesting the need for the state to take greater responsibility for covering this financial risk in the future.

Healthcare utilization and direct medical cost in the years during and after cancer diagnosis in patients with type 2 diabetes mellitus

AIMS/INTRODUCTION

There is uncertainty about the direct medical costs of type 2 diabetes patients with cancers.

MATERIALS AND METHODS

A population-based retrospective cohort of 99,915 type 2 diabetes patients from the Hong Kong Hospital Authority between 2006 and 2017 was assembled. A total of 16,869 patients who had an initial cancer diagnosis after type 2 diabetes diagnosis were matched with 83,046 patients without cancer (controls) using a matching ratio of up to one-to-five propensity score-matching method. Patients were divided into four categories according to life expectancy. Healthcare service utilization and direct medical costs during the index year, subsequent years and mortality year were compared between patients with and without cancer in each category.

RESULTS

Medical costs of cancer patients in the index year ranged from $US27,533 for patients who died in <1 year to $US11,303 for those survived >3 years. Cancer patients had significantly greater expenditures than controls in the index year (all P < 0.001) and subsequent years ($US4,569 vs $US4,155, P < 0.001). Cancer patients also had greater costs in the year of death, and the difference was significant for patients who survived >3 years after the index year ($US32,558 vs $US28,260). For patients in both groups, patients who survived >3 years had significantly lower costs than those who died in <1 year. Costs incurred in the mortality year were greater than those in the index year and subsequent years. Hospitalization accounted for >90% of the medical costs for both groups in the mortality year.

CONCLUSIONS

Type 2 diabetes patients with cancers incurred greater medical costs in the diagnosis, ensuing and mortality years than type 2 diabetes patients without cancers.

Three-gene prognostic biomarkers for seminoma identified by weighted gene co-expression network analysis

Testicular germ cell tumors (TGCTs) are common in young males, and seminoma accounts for a large proportion of TGCTs. However, there are limited records on the exploration of novel biomarkers for seminoma. Hence, we aimed to identify new biomarkers associated with overall survival in seminoma. mRNA-seq and clinical traits of TGCTs were downloaded from UCSC XENA and analyzed by weighted gene co-expression network analysis. After intersection with differentially expressed genes in GSE8607, common genes were subjected to protein-protein interaction (PPI) network construction and enrichment analyses. Then, the top 10 common genes were investigated by Kaplan–Meier (KM) survival analyses and univariate Cox regression analyses. Ultimately, TYROBP, CD68, and ITGAM were considered three prognostic biomarkers in seminoma. Based on correlation analysis between these genes and immune infiltrates, we suggest that the three biomarkers influence the survival of seminoma patients, possibly through regulating the infiltration of immune cells. In conclusion, our study demonstrated that TYROBP, CD68, and ITGAM could be regarded as prognostic biomarkers and therapeutic targets for seminoma patients.

Estimating the Loss in Expectation of Life and Relative Survival Rate among Hemodialysis Patients in Iran

BACKGROUND

Information regarding the prognosis and burden of diseases can be used by policymakers to determine competing health priorities. We aimed to assess the Relative Survival Rate (RSR) and loss of expectation of life (LEL) to evaluate the prognosis and burden of diseases in Hemodialysis (HD) patients.

STUDY DESIGN

A retrospective cohort study.

METHODS

We recruited 648 HD patients referred to three referral centers in Kerman City, Iran, from 2008 to 2019. RSR, was defined as the ratio of the observed and the expected survival rates of general population for persons of the same age and sex as patients in the current study. LEL was determined as the difference between corresponding life expectancies (LE). The extended Cox proportional hazard model was used to identify variables associated with the outcome.

RESULTS

Variables associated with outcome were diabetic status and age. In the 5th year of the follow-up study, the overall RSR was 0.57. In general, for HD patients, the estimation of LE and LEL was 22.6 and 12.36 year, respectively.

CONCLUSION

HD patients, especially older patients, showed a very poor prognosis, with a large amount of lost life expectancy. Therefore, they need more care and attention from health authorities. It is suggested to estimate the cost of eliminating the risk factors causing kidney diseases.

Immune-related genes play an important role in the prognosis of patients with testicular germ cell tumor

Background

Testicular cancer is a very common malignancy in young men. Although testicular cancer has a high cure rate, patients have a high long-term risk of secondary malignant tumors and cardiovascular disease. In addition, for patients resistant to traditional treatment methods, new treatment methods and methods for predicting prognosis are also urgently needed.

Methods

Gene expression profiles of 165 normal testicular tissues and 156 testicular germ cell tumor (TGCT) tissues from GTEx database and TCGA database were used to obtain differentially expressed genes (DEGs) in TGCT. Through the ImmPort database, we obtained immune-related genes (IRGs). Univariate Cox regression analysis was used to identify prognostic IRGs. A transcription factor regulatory network was constructed to clarify the possible regulatory mechanism for the differential expression of these IRGs. Multivariate Cox regression analysis was used to establish a prognostic model. Gene expression data and related survival data of 108 TCGT patients from GEO database were used for external validation. Survival analysis, receiver operating characteristic curves (ROC) curve analysis, independent prognostic analysis, principal component analysis (PCA) and clinical correlation analysis were performed to evaluate this model.

Results

Three hundred and thirty-three IRGs were differentially expressed between TGCT and normal testicular tissues. We established a prognostic model (riskScore) based on 5 risk genes (SEMA6B, SEMA3G, OBP2B, INSL6 and RETN). Whether in the training cohort, the testing cohort or the entire TCGA cohort, this model could accurately stratify patients with different survival outcomes. The prognostic value of riskScore and 5 risk genes was also confirmed in the GEO database. GSEA analysis showed that DEGs in patients with better prognosis were enriched in immune-related pathways, while DEGs in patients with poorer prognosis were enriched in cancer-related pathways and cardiovascular disease-related pathways. Finally, a new Nomogram with higher prognostic value was constructed to better predict the 1-year PFS, 3-year PFS and 5-year PFS of TCGT patients.

Conclusions

We successfully established an immune-related risk model with high prognostic value and created a new Nomogram. We found that different immune status in tumor microenvironment may be responsible for the different survival outcomes among TGCT patients.

Preimplantation Genetic Testing for Polygenic Disease Relative Risk Reduction: Evaluation of Genomic Index Performance in 11,883 Adult Sibling Pairs

Preimplantation genetic testing for polygenic disease risk (PGT-P) represents a new tool to aid in embryo selection. Previous studies demonstrated the ability to obtain necessary genotypes in the embryo with accuracy equivalent to in adults. When applied to select adult siblings with known type I diabetes status, a reduction in disease incidence of 45-72% compared to random selection was achieved. This study extends analysis to 11,883 sibling pairs to evaluate clinical utility of embryo selection with PGT-P. Results demonstrate simultaneous relative risk reduction of all diseases tested in parallel, which included diabetes, cancer, and heart disease, and indicate applicability beyond patients with a known family history of disease.

Exploring the effects of lifestyle on breast cancer risk, age at diagnosis, and survival: the EBBA-Life study

Purpose

Whether an unfavorable lifestyle not only affects breast cancer risk, but also influences age at onset of breast cancer and survival, is under debate.

Methods

In a population-based cohort, the Energy Balance and Breast Cancer Aspects throughout life (EBBA-Life) study, a total of 17,145 women were included. During follow-up, 574 women developed invasive breast cancer. Breast cancer cases were followed for an additional 9.1 years. Detailed medical records were obtained. Cox’s proportional hazard regression models were used to study the association between pre-diagnostic lifestyle factors (weight, physical activity, alcohol use, smoking, and hypertension), breast cancer risk, age at diagnosis, and survival.

Results

At study entry, 34.3% of the participating women were overweight and 30.7% were physically inactive. Mean age at breast cancer diagnosis was 58.0 years, and 78.9% of the tumors were estrogen receptor positive. Among menopausal women who did not use hormone therapy and had an unfavorable lifestyle (3–5 unfavorable factors), compared with women who had a favorable lifestyle, we observed a twofold higher risk for postmenopausal breast cancer (hazard ratio [HR] 2.13, 95% confidence interval [CI] 1.23–3.69), and they were 3.4 years younger at diagnosis (64.8 versus 68.2 years, P = 0.032). Breast cancer patients with an unfavorable lifestyle, compared with patients with a favorable lifestyle, had almost a two times higher overall mortality risk (HR 1.96, 95% CI 1.01–3.80).

Conclusions

Our study supports a healthy lifestyle improving breast cancer prevention, postponing onset of disease, and extending life expectancy among breast cancer patients.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05679-2) contains supplementary material, which is available to authorized users.

Lung Nodule Detection in CT Images Using Statistical and Shape-Based Features

The lung tumor is among the most detrimental kinds of malignancy. It has a high occurrence rate and a high death rate, as it is frequently diagnosed at the later stages. Computed Tomography (CT) scans are broadly used to distinguish the disease; computer aided systems are being created to analyze the ailment at prior stages productively. In this paper, we present a fully automatic framework for nodule detection from CT images of lungs. A histogram of the grayscale CT image is computed to automatically isolate the lung locale from the foundation. The results are refined using morphological operators. The internal structures are then extracted from the parenchyma. A threshold-based technique is proposed to separate the candidate nodules from other structures, e.g., bronchioles and blood vessels. Different statistical and shape-based features are extracted for these nodule candidates to form nodule feature vectors which are classified using support vector machines. The proposed method is evaluated on a large lungs CT dataset collected from the Lung Image Database Consortium (LIDC). The proposed method achieved excellent results compared to similar existing methods; it achieves a sensitivity rate of 93.75%, which demonstrates its effectiveness.

Mock Drills: Implementation for Emergency Scenarios in the Outpatient Setting

BACKGROUND

Oncology care has made the shift to the outpatient setting. The authors' cancer center is a basic life support-certified facility using an affiliated hospital for emergent transfers. A nurse-led initiative was developed in response to expressed anxieties and lack of comfort by staff related to their role in emergency management. Mock drills help staff retain knowledge and skills necessary during an emergency.

OBJECTIVES

This project aimed to create simulation-based scenarios to practice outpatient emergency management skills.

METHODS

Targeted objectives for each scenario were developed by the team with staff input. An evaluation form following the mock drill is used to assess comfort level and attained knowledge.

FINDINGS

Practicing an emergency scenario in a controlled and simulated environment improves provider confidence, communication, teamwork, and patient safety. It is an adaptable strategy that fosters team cohesiveness during actual emergencies. A successful mock drill team encompasses organization, clearly identified roles, and frequent team practice.

Healthy lifestyle and life expectancy free of cancer, cardiovascular disease, and type 2 diabetes: prospective cohort study

OBJECTIVE

To examine how a healthy lifestyle is related to life expectancy that is free from major chronic diseases.

DESIGN

Prospective cohort study.

SETTING AND PARTICIPANTS

The Nurses' Health Study (1980-2014; n=73 196) and the Health Professionals Follow-Up Study (1986-2014; n=38 366).

MAIN EXPOSURES

Five low risk lifestyle factors: never smoking, body mass index 18.5-24.9, moderate to vigorous physical activity (≥30 minutes/day), moderate alcohol intake (women: 5-15 g/day; men 5-30 g/day), and a higher diet quality score (upper 40%).

MAIN OUTCOME

Life expectancy free of diabetes, cardiovascular diseases, and cancer.

RESULTS

The life expectancy free of diabetes, cardiovascular diseases, and cancer at age 50 was 23.7 years (95% confidence interval 22.6 to 24.7) for women who adopted no low risk lifestyle factors, in contrast to 34.4 years (33.1 to 35.5) for women who adopted four or five low risk factors. At age 50, the life expectancy free of any of these chronic diseases was 23.5 (22.3 to 24.7) years among men who adopted no low risk lifestyle factors and 31.1 (29.5 to 32.5) years in men who adopted four or five low risk lifestyle factors. For current male smokers who smoked heavily (≥15 cigarettes/day) or obese men and women (body mass index ≥30), their disease-free life expectancies accounted for the lowest proportion (≤75%) of total life expectancy at age 50.

CONCLUSION

Adherence to a healthy lifestyle at mid-life is associated with a longer life expectancy free of major chronic diseases.

Changes in life expectancy for cancer patients over time since diagnosis

The aims of this study were to provide life expectancy (LE) estimates of cancer patients at diagnosis and LE changes over time since diagnosis to describe the impact of cancer during patients' entire lives. Cancer patients' LE was calculated by standard period life table methodology using the relative survival of Italian patients diagnosed in population-based cancer registries in 1985-2011 with follow-up to 2013. Data were smoothed using a polynomial model and years of life lost (YLL) were calculated as the difference between patients' LE and that of the age- and sex-matched general population. The YLL at diagnosis was highest at the youngest age at diagnosis, steadily decreasing thereafter. For patients diagnosed at age 45 years, the YLL was above 20 for lung and ovarian cancers and below 6 for thyroid cancer in women and melanoma in men. LE progressively increased in patients surviving the first years, decreasing thereafter, to approach that of the general population. YLL in the long run mainly depends on attained age. Providing quantitative data is essential to better define clinical follow-up and plan health care resource allocation. These results help assess when the excess risk of death from tumour becomes negligible in cancer survivors.

Clinical and Genetic Risk Factors for Adverse Metabolic Outcomes in North American Testicular Cancer Survivors

Background: Testicular cancer survivors (TCS) are at significantly increased risk for cardiovascular disease (CVD), with metabolic syndrome (MetS) an established risk factor. No study has addressed clinical and genetic MetS risk factors in North American TCS. Patients and Methods: TCS were aged <55 years at diagnosis and received first-line chemotherapy. Patients underwent physical examination, and had lipid panels, testosterone, and soluble cell adhesion molecule-1 (sICAM-1) evaluated. A single nucleotide polymorphism in rs523349 (5-α-reductase gene, SRD5A2), recently implicated in MetS risk, was genotyped. Using standard criteria, MetS was defined as ≥3 of the following: hypertension, abdominal obesity, hypertriglyceridemia, decreased high-density lipoprotein (HDL) cholesterol level, and diabetes. Matched controls were derived from the National Health and Nutrition Examination Survey. Results: We evaluated 486 TCS (median age, 38.1 years). TCS had a higher prevalence of hypertension versus controls (43.2% vs 30.7%; P<.001) but were less likely to have decreased HDL levels (23.7% vs 34.8%; P<.001) or abdominal obesity (28.2% vs 40.1%; P<.001). Overall MetS frequency was similar in TCS and controls (21.0% vs 22.4%; P=.59), did not differ by treatment (P=.20), and was not related to rs523349 (P=.61). For other CVD risk factors, TCS were significantly more likely to have elevated low-density lipoprotein (LDL) cholesterol levels (17.7% vs 9.3%; P<.001), total cholesterol levels (26.3% vs 11.1%; P<.001), and body mass index ≥25 kg/m² (75.1% vs 69.1%; P=.04). On multivariate analysis, age at evaluation (P<.001), testosterone level ≤3.0 ng/mL (odds ratio [OR], 2.06; P=.005), and elevated sICAM-1 level (OR_{highest vs lowest quartile}, 3.58; P=.001) were significantly associated with MetS. Conclusions and Recommendations: Metabolic abnormalities in TCS are characterized by hypertension and increased LDL and total cholesterol levels but lower rates of decreased HDL levels and abdominal obesity, signifying possible shifts in fat distribution and fat metabolism. These changes are accompanied by hypogonadism and inflammation. TCS have a high prevalence of CVD risk factors that may not be entirely captured by standard MetS criteria. Cancer treatment-associated MetS requires further characterization.

Uncertainty and Quality of Life in Women With Breast Cancer: Moderating Role of Coping Styles

BACKGROUND

The negative relationship between uncertainty and quality of life is well reported in the literature. Also, there is abundant research linking coping strategies to cancer patients' quality of life. However, there exists a paucity of information on the moderating effect of coping styles on the relationship between uncertainty and quality of life in cancer patients.

OBJECTIVE

The aim of this study was to examine whether uncertainty in illness is negatively correlated with quality of life and whether this relationship is moderated by coping strategies, namely, problem-focused, avoidant, and active emotional coping.

METHODS

A convenience sample of 135 Malaysian women with breast cancer participated in the study. Participants completed measures of uncertainty in illness, quality of life, and coping styles.

RESULTS

Uncertainty in breast cancer was negatively related to quality of life (β = -0.379, P < .001), and active emotional coping was found to moderate this negative relationship (β = 0.155, P < .05). The model explained 22.20% of the variance of quality of life.

CONCLUSION

Lack of information about breast cancer, treatment, hospitalization, and disease recurrence is related to poorer quality of life. However, this negative relationship becomes weaker when active emotional coping strategies are used.

IMPLICATIONS FOR PRACTICE

Nurses and health providers should help patients reduce their uncertainty in illness by providing them information on breast cancer or referring them to relevant sources. Moreover, they could reduce the deleterious effect of uncertainty on quality of life by encouraging patients to use more active emotional coping strategies.

Management of Primary Testicular Tumor

In any man with a solid testicular mass, cancer should be considered until proven otherwise. Radical inguinal orchiectomy is the treatment of choice in patients with testis mass. Placement of a testicular prosthesis is safe with a very low complication rate and should be offered to all patients undergoing radical orchiectomy. In patients with widespread or life-threatening advanced disease, delayed orchiectomy following chemotherapy is recommended. Testis-sparing surgery can be performed in highly selected patients with solitary testicle mass, bilateral testicular tumors, or strong suspicion of a benign lesion.

Incorporating Future Medical Costs: Impact on Cost-Effectiveness Analysis in Cancer Patients

BACKGROUND

The inclusion of future medical costs in cost-effectiveness analyses remains a controversial issue. The impact of capturing future medical costs is likely to be particularly important in patients with cancer where costly lifelong medical care is necessary. The lack of clear, definitive pharmacoeconomic guidelines can limit comparability and has implications for decision making.

OBJECTIVE

The aim of this study was to demonstrate the impact of incorporating future medical costs through an applied example using original data from a clinical study evaluating the cost effectiveness of a sepsis intervention in cancer patients.

METHODS

A decision analytic model was used to capture quality-adjusted life-years (QALYs) and lifetime costs of cancer patients from an Australian healthcare system perspective over a lifetime horizon. The evaluation considered three scenarios: (1) intervention-related costs (no future medical cost), (2) lifetime cancer costs and (3) all future healthcare costs. Inputs to the model included patient-level data from the clinical study, relative risk of death due to sepsis, cancer mortality and future medical costs sourced from published literature. All costs are expressed in 2017 Australian dollars and discounted at 5%. To further assess the impact of future costs on cancer heterogeneity, variation in survival and lifetime costs between cancer types and the implications for cost-effectiveness analysis were explored.

RESULTS

The inclusion of future medical costs increased incremental cost-effectiveness ratios (ICERs) resulting in a shift from the intervention being a dominant strategy (cheaper and more effective) to an ICER of $7526/QALY. Across different cancer types, longer life expectancies did not necessarily result in greater lifetime healthcare costs. Incremental costs differed across cancers depending on the respective costs of managing cancer and survivorship, thus resulting in variations in ICERs.

CONCLUSIONS

There is scope for including costs beyond intervention costs in economic evaluations. The inclusion of future medical costs can result in markedly different cost-effectiveness results, leading to higher ICERs in a cancer population, with possible implications for funding decisions.

Adverse Health Outcomes in Relationship to Hypogonadism After Chemotherapy: A Multicenter Study of Testicular Cancer Survivors

BACKGROUND

This study examined the prevalence of hypogonadism, its clinical and genetic risk factors, and its relationship to adverse health outcomes (AHOs) in North American testicular cancer survivors (TCS) after modern platinum-based chemotherapy.

PATIENTS AND METHODS

Eligible TCS were <55 years of age at diagnosis and treated with first-line platinum-based chemotherapy. Participants underwent physical examinations and completed questionnaires regarding 15 AHOs and health behaviors. Hypogonadism was defined as serum testosterone levels ≤3.0 ng/mL or use of testosterone replacement therapy. We investigated the role of 2 single nucleotide polymorphisms (rs6258 and rs12150660) in the sex hormone-binding globulin (SHBG) locus implicated in increased hypogonadism risk in the general population.

RESULTS

Of 491 TCS (median age at assessment, 38.2 years; range, 18.7-68.4 years), 38.5% had hypogonadism. Multivariable binary logistic regression analysis identified hypogonadism risk factors, including age at clinical evaluation (odds ratio [OR], 1.42 per 10-year increase; P= .006) and body mass index of 25 to <30 kg/m2 (OR, 2.08; P= .011) or ≥30 kg/m2 (OR, 2.36; P= .005) compared with <25 kg/m2. TCS with ≥2 risk alleles for the SHBG SNPs had a marginally significant increased hypogonadism risk (OR, 1.45; P= .09). Vigorous-intensity physical activity appeared protective (OR, 0.66; P= .07). Type of cisplatin-based chemotherapy regimen and socioeconomic factors did not correlate with hypogonadism. Compared with TCS without hypogonadism, those with hypogonadism were more likely to report ≥2 AHOs (65% vs 51%; P= .003), to take medications for hypercholesterolemia (20.1% vs 6.0%; P<.001) or hypertension (18.5% vs 10.6%; P= .013), and to report erectile dysfunction (19.6% vs 11.9%; P= .018) or peripheral neuropathy (30.7% vs 22.5%; P= .041). A marginally significant trend for increased use of prescription medications for either diabetes (5.8% vs 2.6%; P= .07) or anxiety/depression (14.8% vs 9.3%; P= .06) was observed.

CONCLUSIONS

At a relatively young median age, more than one-third of TCS have hypogonadism, which is significantly associated with increased cardiovascular disease risk factors, and erectile dysfunction. Providers should screen TCS for hypogonadism and treat symptomatic patients.

Excess risk of dying of other causes of cured cancer patients

BACKGROUND

The proportion of patients cured of cancer is usually estimated with cure models assuming they have the same death risk as the general population. These patients, even when cured, often maintain an extra death risk compared to the overall population. Our aims were to estimate this extra risk, and to take it into account in estimating cure proportions and relative survival (RS).

METHODS

We used RS mixture model with an additional parameter expressing the extra noncancer death risk of patients, assumed constant with age. We applied the model to the SEER registries survival data (1990-1994 diagnosed patients) with colorectal, breast, and lung cancers, and followed up to 2013.

RESULTS

The estimated relative risk of death for cured patients versus the general population was 1.11 for colorectal, 1.16 for breast, and 2.17 and 2.12, respectively, for female and male lung cancers. Taking this extra risk into account leads, for all cancers, to a higher estimated proportion of cured and a lower RS of uncured patients. In addition, it leads to a higher estimated RS for all patients aged >70 years, and for lung cancer patients aged >50 years, at diagnosis.

CONCLUSIONS

Mortality of survivors not directly due to the diagnosed cancer was significantly higher than in the general population. It affected the estimates of cure proportions for all age classes and RS in the elderly.

Long-Term Follow Up of the Erectile Function of Testicular Cancer Survivors

The diagnosis of testicular cancer (TC) can have a considerable and persistent impact on a patient's sexuality, especially given its location. The high prevalence of TC in young adults, and the good prognosis, explain the great interest in sexual dysfunction and its influence on post-treatment quality of life. The aim of this study was to evaluate the impact of the diagnosis and treatments (inguinal orchiectomy and chemotherapy) on sex life. For this purpose, we recruited 241 TC patients attending the Laboratory of Seminology-Sperm Bank "Loredana Gandini" for sperm cryopreservation (mean age 31.3 ± 6.9 years) and 223 cancer-free healthy men who were undergoing andrological screening (mean age 32.0 ± 7.7 years). The IIEF-15 questionnaire was administered at the baseline (post-orchiectomy, pre-chemotherapy-T0) and at 6 (T1), 12 (T2), 18 (T3), 24 (T4), 48 months (T5) and >5 years (T6, median 96 months) after chemotherapy to all patients, to evaluate the following domains: erectile function (EF), orgasmic function (OF), sexual desire (SD), intercourse satisfaction (IS) and overall satisfaction (OS). A subgroup of patients also underwent blood sex hormone analysis for further correlations with IIEF scores. At the baseline, 37.7% of patients had erectile dysfunction (EF score <26) and all IIEF domains except OF showed significantly lower scores than in controls (p < 0.001). Long-term follow-up revealed persistently lower scores in TC survivors than in controls for EF, SD, IS, and OS. Furthermore, most IIEF domains did not improve significantly in TC patients during the duration of the follow-up, with the exception of EF, which showed a significant improvement from T2. Finally, no significant correlation was found between hormone levels (gonadotropin and testosterone) and IIEF-15 scores. In conclusion, TC and its treatment have a significant effect on sexuality. The absence of a clear correlation with biochemical hypogonadism suggests that this may to a large extent be due to the surgical procedure itself, or to the psychological impact of a cancer diagnosis.

Predicting Cardiovascular Disease Among Testicular Cancer Survivors After Modern Cisplatin-based Chemotherapy: Application of the Framingham Risk Score

BACKGROUND

Testicular cancer survivors (TCSs) are at increased risk of cardiovascular disease (CVD) after cisplatin-based chemotherapy (CBCT). Identifying at-risk survivors would allow early intervention, but risk prediction tools such as the Framingham Risk Score (FRS) have not been applied to TCSs given modern chemotherapy.

METHODS

TCSs > 1 year post-CBCT were evaluated. Associations between FRS and clinical, socioeconomic, and lifestyle measures and treatment regimen (4 cycles, etoposide and cisplatin [EP × 4]); 3 or 4 cycles, bleomycin plus EP (BEP × 3, BEP × 4) were analyzed with general linear multivariable models. Controls from the National Health and Nutrition Examination Survey were matched 1:1 to TCSs by age, race, and education with differences in mean FRS evaluated with 2-sided t tests.

RESULTS

Of 787 TCSs (median age, 37.3 years; median follow-up, 4.2 years), 284, 342, and 161 received EP × 4, BEP × 3, or BEP × 4, respectively. TCSs had higher median systolic blood pressure (126 vs. 119 mm Hg; P < .001), but fewer were smokers (8.4% vs. 28.2%; P < .001) than controls. In multivariable analysis, no significant differences in FRS between EP × 4, BEP × 3, and BEP × 4 were observed, but less than college education (P < .001) and lack of vigorous exercise (P = .006) were associated with higher FRS. Mean FRS did not differ between TCSs and controls (6.8% vs. 7.3%; P = .67).

CONCLUSION

This is the first study to apply the office-based FRS to TCSs. Chemotherapy regimen (BEP × 3 vs. EP × 4) was not associated with FRS, but less educated and less vigorously active patients had higher FRS, and present a high-risk subgroup for intense follow-up and counseling.