Original article
Clinical—testis
Marital status independently predicts testis cancer survival—an analysis of the SEER database

https://doi.org/10.1016/j.urolonc.2010.03.005Get rights and content

Abstract

Objectives

Previous reports have shown that married men with malignancies have improved 10-year survival over unmarried men. We sought to investigate the effect of marital status on 10-year survival in a U.S. population-based cohort of men with testis cancer.

Materials and methods

We examined 30,789 cases of testis cancer reported to the Surveillance, Epidemiology, and End Results (SEER 17) database between 1973 and 2005. All staging were converted to the 1997 AJCC TNM system. Patients less than 18 years of age at time of diagnosis were excluded. A subgroup analysis of patients with stages I or II non-seminomatous germ cell tumors (NSGCT) was performed. Univariate analysis using t-tests and χ2 tests compared characteristics of patients separated by marital status. Multivariate analysis was performed using a Cox proportional hazard model to generate Kaplan-Meier survival curves, with all-cause and cancer-specific mortality as the primary endpoints.

Results

20,245 cases met the inclusion criteria. Married men were more likely to be older (38.9 vs. 31.4 years), Caucasian (94.4% vs. 92.1%), stage I (73.1% vs. 61.4%), and have seminoma as the tumor histology (57.3% vs. 43.4%). On multivariate analysis, married status (HR 0.58, P < 0.001) and Caucasian race (HR 0.66, P < 0.001) independently predicted improved overall survival, while increased age (HR 1.05, P < 0.001), increased stage (HR 1.53–6.59, P < 0.001), and lymphoid (HR 4.05, P < 0.001), or NSGCT (HR 1.89, P < 0.001) histology independently predicted death. Similarly, on multivariate analysis, married status (HR 0.60, P < 0.001) and Caucasian race (HR 0.57, P < 0.001) independently predicted improved testis cancer-specific survival, while increased age (HR 1.03, P < 0.001), increased stage (HR 2.51–15.67, P < 0.001), and NSGCT (HR 2.54, P < 0.001) histology independently predicted testis cancer-specific death. A subgroup analysis of men with stages I or II NSGCT revealed similar predictors of all-cause survival as the overall cohort, with retroperitoneal lymph node dissection (RPLND) as an additional independent predictor of overall survival (HR 0.59, P = 0.001), despite equal rates of the treatment between married and unmarried men (44.8% vs. 43.4%, P = 0.33).

Conclusions

Marital status is an independent predictor of improved overall and cancer-specific survival in men with testis cancer. In men with stages I or II NSGCT, RPLND is an additional predictor of improved overall survival. Marital status does not appear to influence whether men undergo RPLND.

Introduction

Testis cancer remains the most common malignancy in males ages 20 to 34 in the United States, and there were an estimated 8,600 new cases diagnosed in 2009. The incidence of testis cancer continues to increase, while the disease-specific mortality continues to decrease. The overall testis cancer-specific 5 year survival is 95% according to the Surveillance, Epidemiology, and End Results (SEER) cases reported between 1999 and 2005, indicative of the overall success in diagnosing and treating this disease [1]. There still exist significant differences, however, in survival of men based on race, tumor histology, and stage at diagnosis [2]. Other socioeconomic and demographic variables also likely play a role in survival in men with testis cancer, as have been demonstrated in other malignancies.

The impact of marital status on testicular cancer survival has not been previously studied to our knowledge. Data does exist to suggest that married men with testis cancer present at an earlier stage than unmarried men [3], however this has not been published in the peer-reviewed literature and the analysis has not been extended to cancer outcome.

The effect of marital status in particular has been studied extensively in a variety of urologic and nonurologic malignancies. A recent article showed that separated patients have decreased cancer survival across a range of malignancies, perhaps due to psychosocial stress [4]. Patients with transitional cell carcinoma of the bladder who are married when diagnosed have been shown to enjoy increased disease-specific survival [5]. Another study failed to show this relationship, however, did demonstrate that widowed men with bladder cancer had significantly decreased survival [6].

The goal of this study was to examine the impact of marital status on overall and testis cancer-specific survival using the SEER registry, a U.S. population based sample.

Section snippets

Data

The data for this study come from the Surveillance, Epidemiology, and End Results (SEER) 17 cancer public use database (1973–2005). The SEER cancer registry identifies patients from 17 representative geographic regions encompassing 26% of the general U.S. population. [Surveillance, Epidemiology, and End Results (SEER) Program (www.seer.cancer.gov) SEER*Stat Database: Incidence - SEER 17 Regs Limited-Use + Hurricane Katrina Impacted Louisiana Cases, Nov 2007 Sub (1973–2005) - Linked To County

Results

Table 1a, Table 1b indicates summary statistics for the analysis sample, stratified by marital status. Patients married at the time of diagnosis were also older at the time of diagnosis, more likely to be of white ethnicity, and presented at earlier stages. These characteristics are also true for the stages I or II NSGCT subgroup.

Total overall mortality was low: 89.1% of the 20,245 total patients were still alive at 10 years following diagnosis. Of the 2,201 who died at 10 years, 962 of these

Discussion

This study is the first to show an independent beneficial effect of marriage on survival in testis cancer. This is likely a multifactorial psychosocial effect on various stages of the disease process, including detection, presentation for treatment, compliance with treatment, treatment decisions, and compliance with surveillance or follow-up after treatment.

Conclusion

Patients who are married at the time of testis cancer diagnosis have better 10 year overall and cancer-specific survival than unmarried patients. Targeting single men with screening and disease awareness programs, maintaining vigilance during surveillance, and offering social support resources such as those provided by the American Cancer Society are possible interventions that may mitigate this phenomenon.

References (17)

There are more references available in the full text version of this article.

Cited by (28)

  • Racial and socioeconomic disparities in retroperitoneal lymph node dissection and survival in nonseminomatous germ cell tumor: A population-based study

    2021, Urologic Oncology: Seminars and Original Investigations
    Citation Excerpt :

    It has been shown for a variety of primary cancers that unmarried patients are more likely to present with highly metastatic disease, receive less treatment, and have worse survival [27]. With regard to testicular cancer, Abern et al., in study of SEER data, found that married men had greater overall and cancer-specific survival, as compared to unmarried men, and that married men received RPLND at the same rate as unmarried men [28]. We found that single patients with stage II disease were less likely to receive RPLND.

  • Contemporary Incidence and Mortality Rates in Patients With Testicular Germ Cell Tumors

    2019, Clinical Genitourinary Cancer
    Citation Excerpt :

    Disease stage represents the other dominant determinant of prognosis. Last but not least, patient characteristics such as age at presentation7 and possibly sociodemographic characteristics,8-11 also represent potential predictors of disease characteristics and/or cancer-specific mortality (CSM). Despite the relative abundance of reports9,12-16 addressing GCTT distribution and cancer control outcomes, the 2 most recent epidemiological studies focused on patients diagnosed between 1973 and 2011 in the United States15 and between 2000 and 2014 in Northern Europe.16

  • Insurance Status and Differences in Treatment and Survival of Testicular Cancer Patients

    2016, Urology
    Citation Excerpt :

    There is an association between marital status and testicular cancer survival. Unmarried testicular cancer patients are known to have poor overall and cancer-specific survival compared to married.17 Clinical observation also suggests that the presence of a partner is associated with patients to seek timely care.

  • Survival advantage of marriage in uterine cancer patients contrasts poor outcome for widows: A Surveillance, Epidemiology and End Results study

    2015, Gynecologic Oncology
    Citation Excerpt :

    Marital status is associated with a survival advantage among patients with a variety of cancers [1–5].

View all citing articles on Scopus
View full text