An Updated Systematic Review of Quantitative Studies Assessing Anxiety, Depression, Fear of Cancer Recurrence or Psychological Distress in Testicular Cancer Survivors

Group-based trajectory modeling for fear of cancer recurrence in cancer survivors: a systematic review

PURPOSE

We aimed to systematically review studies that used a group-based trajectory modeling approach to explore the categories of fear of cancer recurrence (FCR) trajectories and their predictors in cancer survivors.

METHODS

MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science were searched. Three authors independently reviewed the literature for predefined eligibility criteria. The Joanna Briggs Institute critical appraisal tools for Cohort Studies and the Guidelines for Reporting on Latent Trajectory Studies were used to assess the quality of included studies. A qualitative synthesis of the included studies was performed.

RESULTS

Ninety-eight studies were retrieved after removing duplicates, and 11 studies met the criteria for inclusion. There are four types of FCR trajectories: stable, decreasing, increasing, and stable-then-decreasing-then-increasing. The following factors were considered significant predictors of FCR trajectory category in at least one of the included studies: age, race, income, education, employment, cancer stage, physical symptoms, depression, anxiety, satisfaction with medical care, and selected cognitive and behavioral factors.

CONCLUSIONS

There was considerable heterogeneity among the studies included in study design and FCR trajectory results. Factors that significantly predicted FCR trajectory categories mostly focused on psychological characteristics. The correlation of sociodemographic and disease-related predictors with FCR trajectory categories was not consistent among the included studies.

IMPLICATIONS FOR CANCER SURVIVORS

We suggest that future scholars should incorporate more psychological factors when identifying cancer survivors who persistently maintain a high level of FCR and developing FCR mitigation measures.

Testicular Cancer Treatments and Sexuality: A Narrative Review

The incidence of testicular cancer (TC) has been rapidly increasing over the past years. Diagnosis and early treatment have shown good oncological control, guaranteeing the patient different treatment approaches according to histology and tumor stage. Currently, physicians usually prioritize oncological outcomes over sexual outcomes and quality of life, considering as a first aim the overall survival of the patients; however, differently from other neoplasms, quality of life is still strongly affected among TC patients, and sexual outcomes are frequently compromised after each TC treatment. Several studies have suggested that each treatment approach may be associated with sexual dysfunctions, including erectile dysfunction, ejaculatory disorders, fertility issues, and hormonal changes. Since testicular cancer patients are more frequently young men, the subject of this work is substantial and should be analyzed in detail to help specialists in the management of this disease. The aim of the current narrative review is to generally describe every treatment for TC, including surgery, chemotherapy, radiotherapy, and retroperitoneal lymph node dissection, and to establish which sexual dysfunction may be specifically associated with each therapy.

Total Pain and Fear of Recurrence in Post-Treatment Cancer Patients: Serial Mediation of Psychological Flexibility and Mentalization and Gender Moderation

Background: The research indicates that painful experiences can significantly affect the fear of cancer recurrence among cancer survivors, which is a distressing concern that influences both physiological and psychological recovery. This cross-sectional study aims to advance our comprehension of the associations between total pain and the fear of recurrence in post-treatment cancer patients by examining two potential mediators: psychological flexibility and mentalization. Methods: Three hundred and thirty-five participants (aged 22 to 88, 49.1% female) who had finished their cancer treatment completed self-report assessments of total pain, their fear of recurrence, psychological flexibility, and mentalization. Results: The serial mediation analysis showed that all dimensions of total pain were positively and indirectly related to the fear of recurrence through psychological flexibility and mentalization in serial. Additionally, gender was found to moderate these serial mediational effects. Conclusions: In line with the psychological flexibility model, personal capacities to face difficult internal/external problems and interpret one's behavior in motivational terms can counterbalance a patient's negative emotions and feelings related to the illness. Gender factors also determine the way in which post-treatment cancer patients manage potential future anxiety and fears.

Self-perceptions of masculinities and testicular cancer: Qualitative explorations

OBJECTIVE

Masculinities have been explored in men with testicular cancer (TC), though limited contemporary research is available on traditional masculine norms important to masculine self-perception. The purpose of this research was to explore the discourse of TC experience in relation to masculine self-perception.

METHODS

A qualitative descriptive study was conducted consisting of semi-structured interviews with 21 men. Men were aged between 31 and 47 (Mage = 35.7). Most men were diagnosed with Stage 1 cancer (66.6%), all men had finished active treatment and time since diagnosis ranged from 17.3 to 71.8 months (M = 47.2). Independent coding was conducted by two researchers and was refined in coding meetings with authors. Themes were developed in a predominantly deductive manner, and analysis of themes was undertaken using a reflexive analysis approach.

RESULTS

Traditional masculine norms showed differing relationships to masculine self-perception. Two main themes were identified [1] Maintained or enhanced masculine self-perception and [2] threats to masculine self-perception. Subthemes demonstrated that maintaining emotional control, strength and 'winning' was important to men, and reduced physical competencies (i.e., strength, sexual dysfunction, virility) challenged self-perception. Strict adherence to traditional norms in response to threatened self-perception related to psychological distress.

CONCLUSION

Leveraging traditionally masculine norms such as physical strength and control and developing flexible adaptations of masculinities should be encouraged with men with TC to retain self-perception and potentially enable better coping. Masculine self-perception of gay/bisexual men may centre around sexual functioning, though further research is required.

"In My Mind, It Was Just Temporary": A Qualitative Study of the Impacts of Cancer on Men and Their Strategies to Cope

Individuals who are diagnosed and treated for cancer use a variety of strategies to manage its impacts. However, there is currently a lack of research on men's experience with managing cancer impacts, which is necessary to better support them throughout the cancer care continuum. This study explored the experience of men diagnosed with cancer, focusing on the impacts of the illness and its treatment and men's strategies to cope. A qualitative descriptive design was used. Thirty-one men (Mage = 52.7 [26-82] years) diagnosed with various cancer types were recruited to take part in individual telephone interviews (n = 14) or online focus groups (n = 17) addressing the impacts of cancer and strategies they used to cope with these impacts. Directed content analysis was performed, using Fitch's (2008) supportive care framework to guide the analysis. Cancer impacts and strategies used to cope were classified into six categories: physical, psychological, interpersonal, informational, practical, and spiritual. Results indicate that the cancer experience is diverse and multifaceted rather than homogeneous. Medical and supportive care services could be more effectively personalized to meet the diversity of men's needs by adopting a comprehensive and holistic approach to supportive care. Working in partnership with patients, it appears promising to recognize and identify men's needs and match them to appropriate resources to provide truly supportive care.

Malignancy, masculinities, and psychological distress: Comparisons made between men with testicular cancer and healthy controls

OBJECTIVE

Psychological distress is common in men with testicular cancer (TC), and masculinities may work to explain this. This study aimed to compare masculinities and distress in TC and healthy control (HC) populations and explore relationships between correlates of distress (psychological flexibility and coping style) and masculinities in TC.

METHODS

A cross-sectional, online survey was completed by 92 men with TC (Mage  = 34.8) and 90 HC (Mage  = 30.7). Measures included psychological distress (Patient-Reported Outcomes Measurement Information System Depression/Anxiety, fear of cancer recurrence inventory-short form), masculinities (gender role conflict-short form, inventory of subjective masculinity experiences/subjective masculinity stress scale, masculinity in chronic disease inventory), coping style (mini-mental adjustment to cancer ) and psychological flexibility (comprehensive assessment of acceptance commitment therapy). Linear regressions were conducted to compare groups and analyse associations.

RESULTS

There were no differences in masculinities or psychological distress between populations (all p > 0.05 and all Cohen's d < 0.20), except for subjective masculine stress and restrictive affectionate behaviour between men. For men with TC, restrictive affection/emotion, conflicts between family/work and subjective masculine stress were associated with psychological distress (rs 0.21-0.58). Optimistic action was negatively associated with depression/anxiety, helplessness/hopelessness coping (rs -0.27 to -0.42) and positively associated with psychological flexibility (r = 0.35).

CONCLUSIONS

Masculinities are implicated in psychological distress in men with TC. Psychological flexibility as well as leveraging masculine beliefs (e.g., optimistic action) may be modifiable targets to reduce distress in men with TC.

Testicular Cancer: The Unmet Needs of a Younger Generation of Cancer Survivors

Unmet holistic needs of various cancer populations, with examples including prostate, bladder, gynecologic, kidney, penile, breast, and colorectal, along with holistic impacts of cancer on older adults, have been defined by a growing number of systematic reviews. Unfortunately, there continues to be a lack of clinical insight into the unique needs of younger men with testicular cancer. Survival rate based on low mortality rates and good prognosis if early detection and treatment implementation grows the number of men who need support as long-term survivors with an average life expectancy of approximately 30 to 50 years after treatment. Providers and clinicians need to approach testicular cancer survivors with the tools and strategies that meet these unmet needs for navigation from diagnosis through survivorship. When strategies of specific resources and education are implemented based on the unique needs of these individuals, positive outcomes and increased health care-related quality of life will be prevalent.

An exploration of testicular cancer survivors' experience of ejaculatory dysfunction following retroperitoneal lymph node dissection-a sub-study of the PREPARE clinical trial

PURPOSE

Ejaculatory dysfunction secondary to retrograde ejaculation or anejaculation is a complication of retroperitoneal lymph node dissection (RPLND) for survivors of testicular cancer. We explored survivors' experiences of ejaculatory dysfunction following RPLND.

METHODS

In a sub-study of a single-arm phase 2 clinical trial (ACTRN12622000537752/12622000542796), participants reporting ejaculatory dysfunction ≥ 6 months following RPLND were invited to complete semi-structured interviews. Purposive sampling was used. Interviews continued until thematic saturation occurred, and codebook thematic analysis of interviews was performed.

RESULTS

Of 58 individuals recruited to the trial, 33 (57%) reported ejaculatory dysfunction. Of these, 32 (97%) agreed to interview and 15 participated. Participants interviewed had median age 34 years (range 24-66), 12 (80%) in a long-term relationship with median time from surgery 36 months (range 11-112). Three overarching themes were identified. The first reflected the value of RPLND despite ejaculatory dysfunction. The second illuminated the impact(s) of ejaculatory dysfunction closely mapped to life stage, with flow-on impacts to fertility, sex, psychological wellbeing and communication. The third reflected information needs. Fertility was a substantial source of concern for some participants. Ejaculatory dysfunction had no effect on sex for some, whilst for others, sex was less pleasurable. Some reported benefits. Few reported ejaculatory dysfunction challenged masculinity, confidence, or self-esteem.

CONCLUSIONS

Future research should examine interventions to reduce distress related to fertility, challenged masculinity and body image.

IMPLICATIONS FOR CANCER SURVIVORS

Whilst most participants considered ejaculatory dysfunction to have little impact on their sexual function and relationships, some reported significant difficulties varying by life stage and relationship status.

Familial aspects of fear of cancer recurrence: current insights and knowledge gaps

Fear of cancer recurrence is fear or worry about cancer recurrence or progress. Fear of recurrence can impact patients' quality of life and wellbeing. Cancer survivors' families support them practically and emotionally, making them a vital supplement for official healthcare. Given the well-established important role of the family in dealing with cancer, we compiled the studies that examined the relationship between family-related factors and fear of cancer recurrence (FCR) among cancer survivors (CSs). One of the foremost studies in this field is the FCR model presented by Mellon and colleagues, which included concurrent family stressors and family-caregiver FCR as factors linked to survivor FCR. Our goal was to prepare the ground for a family-based model of FCR that is more comprehensive than the one proposed by Mellon et al. sixteen years ago. The studies included those with samples of adult cancer survivors from different regions of the world. Most of the studies we reviewed are cross-sectional studies. We categorized family-related factors associated with survivor FCR into partner-related factors, including subgroups of disclosure to partner, cognitions of partner, and partner's sources of support; parenthood-related factors, including having children and parenting stress; family-related factors, including living situation, family history of cancer, family's perception of the illness, and family characteristics; and social interactions including social support, disclosure, social constraints, and attitudes of others. This review sheds light on how significant others of cancer survivors can affect and be affected by cancer-related concerns of survivors and emphasizes the necessity of further investigation of family-related factors associated with FCR.

Goal-Focused Emotion-Regulation Therapy (GET) in Young Adult Testicular Cancer Survivors: A Randomized Pilot Study

BACKGROUND

Young adult testicular cancer survivors experience adverse impacts after treatment. We developed Goal-focused Emotion-regulation Therapy (GET) to improve distress symptoms, emotion regulation, and goal navigation skills.

PURPOSE

This pilot study examined GET versus an active control intervention in young adult survivors of testicular cancer.

METHODS

Seventy-five eligible survivors treated with chemotherapy were randomized to receive GET or Individual Supportive Listening (ISL). Study acceptability, engagement, and tolerability were examined, and intervention fidelity and therapeutic alliance were compared between arms. Preliminary efficacy was evaluated by effect sizes for between-group changes in primary (anxiety and depressive symptoms) and secondary (career confusion, goal navigation, and emotion regulation) outcomes from baseline to immediately and 3-month post-intervention.

RESULTS

Among the 38 men randomized to GET, 81.1% completed all study sessions compared with 82.4% of the 37 men assigned to ISL. Fidelity to the intervention was 87% in GET. Therapeutic alliance wassignificantly higher among those receiving GET versus ISL. Participants exhibited a medium group-by-time effect size with greater reductions in depressive (d = 0.45) and anxiety (d = 0.29) symptoms for those in GET versus ISL, with a similar pattern at 3 months for depressive (d = 0.46) and anxiety (d = 0.46) symptoms.

CONCLUSIONS

GET is a feasible and acceptable intervention for reducing adverse outcomes after testicular cancer for young adults. Observed effect sizes preliminarily suggest meaningful change, though should be interpreted with caution in small samples. GET may be a developmentally-matched behavioral approach to improve psychosocial function in this cancer group.

CLINICAL TRIAL INFORMATION

Clinicaltrials.gov, NCT04150848. Registered on October 28, 2019.

Sonoelastography for Testicular Tumor Identification: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy

The objective of this review was to summarize the applications of sonoelastography in testicular tumor identification and inquire about their test performances. Two authors independently searched English journal articles and full conference papers from CINAHL, Embase, IEEE Xplore®, PubMed, Scopus, and Web of Science from inception and organized them into a PIRO (patient, index test, reference test, outcome) framework. Eleven studies (n = 11) were eligible for data synthesis, nine of which (n = 9) utilized strain elastography and two (n = 2) employed shear-wave elastography. Meta-analyses were performed on the distinction between neoplasm (tumor) and non-neoplasm (non-tumor) from four study arms and between malignancy and benignity from seven study arms. The pooled sensitivity of classifying malignancy and benignity was 86.0% (95%CI, 79.7% to 90.6%). There was substantial heterogeneity in the classification of neoplasm and non-neoplasm and in the specificity of classifying malignancy and benignity, which could not be addressed by the subgroup analysis of sonoelastography techniques. Heterogeneity might be associated with the high risk of bias and applicability concern, including a wide spectrum of testicular pathologies and verification bias in the reference tests. Key technical obstacles in the index test were manual compression in strain elastography, qualitative observation of non-standardized color codes, and locating the Regions of Interest (ROI), in addition to decisions in feature extractions. Future research may focus on multiparametric sonoelastography using deep learning models and ensemble learning. A decision model on the benefits-risks of surgical exploration (reference test) could also be developed to direct the test-and-treat strategy for testicular tumors.

Improving adherence and health outcomes in testicular cancer survivors using a mobile health-based intervention: A mixed-methods pilot study

Objective

Testicular cancer (TC) is one of the most common cancers among young men, with survival rates exceeding 97% due to effective treatments. Post-treatment follow-up care is important for long-term survival and monitoring psychosocial symptoms, yet TC survivors (TCS) show poor adherence to post-treatment care. Mobile-health-based interventions show high acceptability in men with cancer. This study will examine the feasibility of using the Zamplo health app to improve adherence to post-treatment care and support psychosocial outcomes in TCS.

Methods

This mixed-methods, longitudinal, single-arm pilot study will recruit N = 30 patients with a diagnosis of TC who finished treatment within ≤ 6 months and are currently aged ≥18 years old. Adherence to follow-up appointments (e.g. blood work, scans) will be assessed (primary outcome), and measures for fatigue, depression, anxiety, sexual satisfaction and function, social roles satisfaction, general mental and physical health and body image (secondary outcomes) will be completed at four-time points: baseline, 3, 6 and 12 months. One-on-one semi-structured interviews will be conducted post-intervention (month 12).

Results

Improvements in post-treatment follow-up appointment adherence and psychosocial outcomes will be analyzed using descriptive statistics, paired samples t-tests to determine changes across time points 1 through 4, and correlation analysis. Qualitative data will be analyzed using thematic analysis.

Conclusion

Findings will inform future, larger trials that incorporate evaluation of sustainability and economic implications to improve adherence to TC follow-up guidelines. Findings will be disseminated via infographics, social media, publications and presentations conducted in partnership with TC support organizations and at conferences.

The impact of testicular cancer and its treatment on masculinity: A systematic review

OBJECTIVE

The purpose of this review was to synthesise the literature on the topic of masculinity and testicular cancer (TC) and investigate the relative impact of TC on men's view of their masculinity.

METHODS

Searches were conducted across four databases (MEDline, PsycInfo, CINAHL Plus and Scopus) for articles published before April 2022 that included (1) TC and (2) masculinity. Two researchers independently rated studies for inclusion with a third resolving conflicts. Of the 6464 articles screened, 24 articles (10 quantitative and 14 qualitative) were included in the review. Articles were rated for quality and a narrative synthesis was performed.

RESULTS

Overall, results indicated some men experience a shift in the way they relate to their sense of masculinity following diagnosis and treatment for TC. Being single and without children was related to the experience of negative masculinity-related outcomes, possibly due to a compounding lack of relational support and being unable to conform to protector, provider traditions. Men who described testicle loss as symbolic of their diminished masculinity were also negatively impacted. However, recent, high-quality literature on the topic using standardised masculinity measures was limited.

CONCLUSION

Some men experience a reduced sense of masculinity after TC, however the impact of TC on masculinity remains person dependent. Further research using validated masculinity measures is required to uncover psycho-social variables that may account for whether and how meaning is made between TC and its treatment and any subsequent impact on perceived masculinity. Such factors may better support these men in life beyond cancer.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO. International Prospective Register of Systematic Reviews: CRD42020185649.

Patient Reported Outcomes, Paternity, Relationship, and Fertility in Testicular Cancer Survivors: Results from a Prospective Observational Single Institution Trial

PURPOSE

Testicular cancer (TC) is the most common solid tumor in young adults. 95% of patients are cured, but they may experience late adverse effects (anxiety, fear of recurrence, and sexual dysfunction) with an impact on daily life. We attempted to assess Patient Reported Outcomes (PROMs), long-term sexual disorders, and difficulties in achieving fatherhood in a cohort of TC survivors, as well as their possible correlation with previous cancer treatments.

METHODS

Different questionnaires, such as the Impact of Cancer (IOC) and the Body Image Scale (BIS), were used to investigate the distinct areas of the PROMs. International Index of Erectile Function (IIEF15) and the Premature Ejaculation Diagnostic Tool (PEDT) focused on sexuality and fertility. Patients were prospectively recruited between February 2020 and February 2022.

RESULTS

144 participants completed all the questionnaires. Results showed a good QoL, a moderate fear of TC recurrence, a good satisfaction with their personal body image, low incidence of premature ejaculation and erectile dysfunction. 19.5% of patients who had a testicular implant reported general dissatisfaction. Only 18% of patients had unsuccessfully attempted fatherhood, while the majority had not yet tried, and 23.4% succeeded. A low percentage of patients used procedures assisted reproduction and adoption.

CONCLUSION

This trial supports the use of various questionnaires as a multifactorial tool capable of investigating all the aspects of long-term cancer survivorship. The assessment of medical and psychosocial sequelae is an essential part of patient care and is important for the development of a comprehensive care plan for TC survivors.

Patient-Reported Outcomes Associated with Treatments for Testicular Cancer: A Systematic Review

Background

Testicular cancer and its treatment can have major short- and long-term effects on the health-related quality of life of those affected. This systematic review aims to summarise patient-reported outcome (PRO) data concerning health-related quality of life, functional impacts and common side-effects of treatments for testicular cancer.

Methods

We systematically searched Medline OVID, CINAHL, PubMed, Embase and the Patient-Reported Outcomes Over Time In Oncology (PROMOTION) databases from inception to 25 March 2020, using "testicular cancer" and "PRO" search terms developed in conjunction with a medical librarian. Two authors screened abstracts and full-text articles for studies that reported primary PRO data related to the treatment of testicular cancer including at least 50 participants. We excluded psychosocial data as this was included in our companion review. Data were extracted by three reviewers, and quality was assessed by two reviewers using QUAL-SYST. Studies with a quality of score over 65% were included in our narrative synthesis.

Results

A total of 1831 records were identified via our database searches and 41 met inclusion criteria. Of these, 35 included participants who had chemotherapy. Twenty-eight different PRO measures were used across the 41 studies. Of the 41 studies, 29 had quality scores over 65% and were included in our narrative synthesis. We found that chemotherapy was generally associated with a higher side-effect burden than other treatments, and higher burden was associated with higher doses of chemotherapy. Hearing problems, peripheral neuropathy, and Raynaud's phenomena were particularly common side-effects. Problems with sexual functioning were associated with chemotherapy, radiotherapy and surgery.

Discussion

While many studies found that between-treatment differences resolved within the first 12 months since diagnosis, there were many long-term and dose-dependent impacts associated with chemotherapy and radiotherapy across PRO domains. Offering information about these aspects, and information about expected survival outcomes, will help inform, prepare, and empower patients to make decisions about treatment aligned with their preferences and personal situations.