Actual frequency of imaging during follow-up of testicular cancer in Israel-a comparison with the guidelines.

OBJECTIVES: Computed tomography (CT) examinations are frequent in follow-up care of testicular cancer (TC) but may increase the risk for other cancers. We wanted to assess the actual number of CT and X-ray examinations within the first 5 years after a diagnosis of TC in Israel during 2003-2007. METHODS: The database of Maccabi Healthcare Services, Israel, was searched for TC patients diagnosed in 2003 to 2007 by direct linkage with the Israel National Cancer Registry. Data on diagnostic imaging examinations (CT of chest, abdomen, or pelvis, unspecified sites; X-ray of chest) were extracted during a 5-year follow-up for 226 incident patients. The actual number of CT and X-ray examinations was compared to the National Comprehensive Cancer Network (NCCN) guideline. We tabulated the median with 10th and 90th percentiles (P10, P90) for the number of CTs and X-rays considering histology, stage, and adjuvant strategy. RESULTS: The number of abdomen or pelvis CTs for TC patients receiving chemo- or radiotherapy was in accordance with the NCCN guideline. The median of abdomen or pelvis CTs for surveillance patients was 8.5 (P10, P90: 3; 13) for nonseminoma and 5.0 (P10, P90: 5; 13) for seminoma patients compared to 14 to 17 CTs recommended. The number of chest X-rays was lower than recommended in the guideline for all adjuvant strategies. CONCLUSIONS: The NCCN guidelines regarding CTs were met for TC patients treated with chemo- or radiotherapy but fell below recommendations for surveillance. Guidelines from 2011 and 2012 were updated in favor of fewer CTs during surveillance. KEY POINTS: • The number of CTs followed the NCCN guidelines in patients treated with chemo- or radiotherapy. • Surveillance patients received fewer CTs and X-rays than recommended in the NCCN guidelines from 2005. • The number of applied CT examinations corresponded to a radiation dose that did not substantially raise the lifetime risk for cancer.

Testicular cancer among US men aged 50 years and older.

BACKGROUND: The incidence of testicular cancer in the United States (US) has substantially increased in recent decades. The majority of testicular cancers are germ cell tumors (TGCT), which are the most commonly occurring malignancies among men aged 15-44 years in the US. To date, few studies have focused on testicular cancer among men aged ≥ 50 years. Thus, we sought to examine detailed descriptive features, including incidence rates and age patterns, of tumors that arise in the testes among men aged ≥ 50 years. METHODS: Data from forty-one US cancer registries were included for the years 1999-2014. Incidence rates per 100,000 person-years and their 95% confidence intervals (CI) were calculated by race/ethnicity, histology, and age at diagnosis. Estimates of annual percent change (APC) were also calculated. RESULTS: Age-specific incidence rates of spermatocytic tumors, sex cord stromal tumors and lymphomas rose with age, while age-specific incidence rates of seminomas and nonseminomas declined. Between 1999 and 2014, the incidence of nonseminoma (APC = 3.26, 95% CI: 2.27-4.25) increased more than any other tumor type. The incidence of seminoma (APC: 1.15, 95% CI: 0.59-1.71) also increased, while rates of testicular lymphoma (APC: -0.66, 95% CI: -1.16 to -0.16), spermatocytic tumors (APC: 0.42, 95% CI: -1.42 to 2.29), and sex cord stromal tumors (APC: 0.60, 95% CI: -3.21 to 4.55) remained relatively unchanged. CONCLUSION: Given the distinct time-trends and age-specific patterns of testicular cancer in men aged ≥50 years, additional investigation of risk factors for these tumors is warranted.

A novel method for identifying settings for well-motivated ecologic studies of cancer.

A low within-country variability and a large between-country variability in cancer incidence may indicate that ecologic factors are involved in the etiology of the disease. The aim of this study is to explore the within- and between-country variability of cancer incidence to motivate high-quality ecologic studies. We extracted age-standardized incidence rate estimates (world standard population) from 135 regions for the ten most frequent invasive cancers in Europe for non-Hispanic white populations from Cancer Incidence in Five Continents, Volume X. We fitted weighted multilevel Poisson regression models with random country effects for each cancer and sex. We estimated intraclass correlation coefficients (ICCs) and 95% confidence intervals (95% CIs). A high ICC indicates a low within- and a high between-country variability of rates. The two cancer sites with the highest ICC among men were prostate cancer (0.96, 95% CI: 0.92-0.99) and skin melanoma (0.78, 0.64-0.93). Among women, high ICCs were observed for lung cancer (0.84, 0.73-0.95) and breast cancer (0.80, 0.69-0.91). The two most prominent sex differences for ICC occurred for cancers of the head and neck (men: 0.70, 0.55-0.85, women: 0.19, 0.08-0.30) and breast cancer (men: 0.04, 0.01-0.07, women: 0.80, 0.69-0.91). ICCs were relatively low for pancreatic cancer (men: 0.23, 0.10-0.35; women: 0.13, 0.04-0.21) and leukemia (men: 0.12, 0.04-0.21; women: 0.08, 0.02-0.14). For cancers with high ICC for which systematic factors of the health care system, screening and diagnostic activities are not plausible explanations for between-country variations in incidence, cross-country sex-specific ecologic studies may be especially promising.

Mortality of Testicular Cancer in East and West Germany 20 Years after Reunification: A Gap Not Closed Yet.

BACKGROUND: The decline of testicular cancer mortality in East Germany began in the 1980s, about 10 years later than that recorded in West Germany. We aimed at providing up-to-date time trends of testicular cancer mortality rates in Germany. MATERIAL AND METHODS: Mortality data from East Germany (1971-2010) and West Germany (1954-2010) were provided by the Federal Bureau of Statistics. We estimated age-specific and age-standardized mortality rates using the World Standard Population. RESULTS: Despite the declining trend in the 2000s, the mortality rates of testicular cancer remained higher in East than in West Germany. These rates were 5.5 and 2.6 per million person-years in 2010, respectively. Age-specific mortality trends by period and birth cohort showed that the mortality decline was larger among younger (15-44 years) than elderly men. CONCLUSION: The mortality of testicular cancer is still higher in East than West Germany. Despite very similar densities of hospital beds, urologists and oncologist per million male population in both parts of Germany, we hypothesized that a paucity of centers of expertise for treating testicular cancers in the East could account for this particular pattern.

Risk of contralateral second primary breast cancer according to hormone receptor status in Germany.

INTRODUCTION: Hormone receptor (HR) status has become an established target in treatment strategies of breast cancer. Population-based estimates of contralateral breast cancer (CBC) incidence by HR subtype in particular are limited. The aim of this study was to provide detailed data on CBC incidence for Germany. METHODS: Invasive breast cancer data were extracted on 49,804 women yielding 594 second primaries from the cancer registries of the Federal States of Brandenburg and Saarland and the area of Munich for the period from 1998 to 2007. Multiple imputation was used on missing values for HR status. We estimated standardized incidence ratios (SIRs) with 95% confidence intervals (95%CIs). RESULTS: SIR estimates of CBC among women diagnosed with an invasive first primary breast cancer (FBC) of any HR subtype ranged from 1.0 to 1.5 in the three registries. Pooling three registries' data, the SIR of HR-positive CBC was 0.7 (95%CI: 0.6 to 0.8) among women with HR-positive FBC. For those women with HR-negative FBC, the SIR of HR-negative CBC was 8.9 (95%CI: 7.1 to 11.1). Among women with FBC diagnosed before the age of 50 years, incidence of CBC was increased, especially for HR-negative FBC (SIR: 9.2; 95%CI: 7.1 to 11.9). CONCLUSIONS: HR status of the first primary and age at first diagnosis is relevant for predicting risk of CBC. Particularly, patients with HR-negative FBC had elevated risks.

Risk of second primary cancers after testicular cancer in East and West Germany: a focus on contralateral testicular cancers.

Testicular cancer survival rates improved dramatically after cisplatin-based therapy was introduced in the 1970s. However, chemotherapy and radiation therapy are potentially carcinogenic. The purpose of this study was to estimate the risk of developing second primary cancers including the risk associated with primary histologic type (seminoma and non-seminoma) among testicular cancer survivors in Germany. We identified 16 990 and 1401 cases of testicular cancer in population-based cancer registries of East Germany (1961-1989 and 1996-2008) and Saarland (a federal state in West Germany; 1970-2008), respectively. We estimated the risk of a second primary cancer using standardized incidence ratios (SIRs) with 95% confidence intervals (95% CIs). To determine trends, we plotted model-based estimated annual SIRs. In East Germany, a total of 301 second primary cancers of any location were observed between 1961 and 1989 (SIR: 1.9; 95% CI: 1.7-2.1), and 159 cancers (any location) were observed between 1996 and 2008 (SIR: 1.7; 95% CI: 1.4-2.0). The SIRs for contralateral testicular cancer were increased in the registries with a range from 6.0 in Saarland to 13.9 in East Germany. The SIR for seminoma, in particular, was higher in East Germany compared to the other registries. We observed constant trends in the model-based SIRs for contralateral testicular cancers. The majority of reported SIRs of other cancer sites including histology-specific risks showed low precisions of estimated effects, likely due to small sample sizes. Testicular cancer patients are at increased risk especially for cancers of the contralateral testis and should receive intensive follow-ups.

Incidence patterns and trends of malignant gonadal and extragonadal germ cell tumors in Germany, 1998-2008.

BACKGROUND: Malignant gonadal (GGCT) and extragonal germ cell tumors [GCT (EGCT)] are thought to originate from primordial germ cells. In contrast to well reported population-based data of GGCTs in males, analyses of GGCTs in females and EGCTs in both sexes remain limited. METHODS: In a pooling project of nine population-based cancer registries in Germany for the years 1998-2008, 16,883 malignant GCTs and their topographical sites were identified using ICD-O morphology and topography for persons aged 15 years and older. We estimated age-specific and age-standardized incidence rates. RESULTS: Among males, the incidence of testicular GCTs increased over time. In contrast, there was no increase in the incidence of EGCTs. Among females, rates of ovarian GCTs were stable, while rates of EGCTs declined over time. The most frequent extragonadal sites were mediastinum among males and placenta among females. CONCLUSIONS: Our results underline different incidence trends and distinct age-specific incidence patterns of malignant GGCTs and EGCTs, as reported recently by several population-based registries. The differences suggest that GGCT and EGCT may have different etiologies.

Frequency of computed tomography examinations in the follow-up care of testicular cancer patients - an evaluation of patterns of care in Germany.

BACKGROUND: Exposure to radiation resulting from diagnostic imaging procedures probably increases late cancer risk. Patterns of care regarding the application of computed tomography (CT) imaging in testicular cancer patients were investigated. METHODS: The database of a large German health insurance company comprising 850,000 insured men was searched for cases of testicular cancer arising in the years 2005 and 2006. The number of CT scans applied during a 3-year period of follow-up was noted for each individual patient and the resulting cumulative radiation dose was estimated. The number of CT scans actually observed was compared to guideline recommendations. RESULTS: 177 patients were identified. Within the 3-year observation period, patients received a mean of 4.4 CT scans (standard error: 0.4) whereas a number of 6.2 would have been expected according to contemporary guidelines. Patients were exposed to an estimated total median diagnostic radiation dose of 30 millisieverts (mSv) (interquartile range: 10-54 mSv). CONCLUSION: There is a considerable gap between recommendation and actual performance regarding the number of CT scans applied to testicular cancer patients. Unfamiliarity of clinicians with guidelines as well as poor acceptance of high numbers of CT scans scheduled may have contributed to create this particular pattern of care.

Radio-opacity and incidental identified mechanical complications of totally implantable venous access devices placed in the chest.

BACKGROUND: Totally implantable venous access devices (TIVAD) may be associated with different complications. Certain mechanical port disorders can easily be diagnosed on chest radiographs if the implanted systems are radiopaque and well visible. There are no reports regarding the visibility of TIVAD on chest X-rays. PURPOSE: To assess the radio opacity of TIVAD implanted in the chest as well as type and frequency of mechanical complications of ports on chest X-ray images. MATERIAL AND METHODS: Chest X-rays of 985 patients from the time period 2007-2009 were analyzed retrospectively. In these patients 1190 TIVAD were inserted. All parts of the TIVAD, i.e. port chamber, connection, and port catheter, were checked for their visibility on chest radiographs. An opacity score was used here as follows: ++ well visible; + visible; - partly or completely invisible. Mechanical complications of TIVAD incidentally detected on chest X-ray were also analyzed retrospectively. RESULTS: Nineteen TIVAD models with diverse configuration and visibility of port chambers, connections, and catheters were identified in our study. Eighty-eight percent of the analyzed port systems were well visible or visible on chest radiographs. Twelve percent of the port chambers and catheters were partly visible or completely invisible. In 9% of the TIVAD, different mechanical complications were diagnosed on chest X-ray images. CONCLUSION: TIVADs should be evaluated carefully on every chest X-ray. Ideally, they should be radio-opaque and well visible on thoracic X-ray images. Unfortunately, this is not always the case. Therefore, manufacturers of TIVAD should take into consideration to use exclusively radio-opaque materials that allow sufficient visibility of each port component on chest radiographs.

Population-based hormone receptor-specific incidence trends of breast cancer in Germany.

OBJECTIVES: Several countries reported a drop in prescription of hormone replacement therapy (HRT) in the 2000s, followed by decreases in breast cancer incidence among postmenopausal women aged 50-69 years. The aim of this study was to provide hormone receptor specific incidence rates of breast cancer in Germany. METHODS: Breast cancer data were extracted from the cancer registries of the Federal States of Brandenburg and Saarland and the area of Munich for the period from 1998 to 2007. We obtained nationwide data on HRT prescription in 1998-2007 from health insurances. Multiple imputation was used on missing values for the receptor status. Age-standardized (European standard population) and age-specific rates were calculated. RESULTS: The age-standardized incidence rates in breast cancer were virtually constant over the entire period in all regions. In particular, no substantial changes over time occurred within the age- and receptor-specific analyses. In the same period we observed a drop in HRT use, starting in 1999 and leveling off in 2004. The incidence trends of carcinoma in situ of the female breast increased during the study period. CONCLUSIONS: In our data, we did not observe an association between the decline in HRT prescription and breast cancer incidence among women aged from 50 to 69 years. The lack of temporal changes in breast cancer incidence may be explained by introduction of opportunistic and organized mammography screening and low absolute levels of HRT prescription in Germany.