Introduction:

Testicular neoplasms, though infrequent overall, are the most common tumors in men aged 20-40, with 95% classified as seminoma and non-seminomatous germ cell tumors. In the U.S., the incidence is approximately 1 per 250 males, showing a rise over recent decades, while mortality rates have decreased. For stage I or IIA nonseminomatous germ cell tumors, primary retroperitoneal lymph node dissection (RPLND) provides crucial therapeutic and diagnostic benefit due to the tumor's limited metastatic spread. Disparities persist in testicular cancer outcomes partly due to limited access to high volume specialty surgical care, and based on race and ethnicity with increased mortality noted for Hispanic men. This study aims to explore these disparities further by analyzing clinical outcomes, including presentation and surgical management, across rural and urban areas using the National Cancer Database (NCDB), to better understand how geographical factors influence testicular cancer outcomes.

Methods:

Our retrospective study, utilizing the NCDB, explores disparities in testicular cancer outcomes among men diagnosed with seminoma (SGCT) and nonseminomatous germ cell tumors (NSGCT). Individuals were assigned to geographic areas using Rural-Urban continuum codes (RUCCs) for their county of residence at the time of diagnosis: large metropolitan (population ≥1 million), medium metropolitan (population 250,000-1 million), small metropolitan (population <250,000), urban (population 2,500->20,000), and rural (population <2,500).  Univariate analysis examined sociodemographic, clinical, and treatment variables. Risk of mortality across the rural-urban continuum was assessed using multivariable Cox regression adjusted for age, pathologic stage, chemotherapy, radiation therapy, race, insurance, surgery type, and area of residence. Kaplan-Meier survival curves assessing mortality based on residence and distance from treating facility were also generated. We also assessed long-term survivorship by examining mortality from time of diagnosis.

Results:

Our cohort of 100,805 had a geographic breakdown of large- (N=55,910), medium- (N=22,089), small-metropolitan (N=9,804), urban (N=11,692), and rural (N=1,310). Disparities were observed including age at diagnosis (p=0.016), race/ethnicity, insurance coverage, educational attainment, and income (all with p<0.001). Unadjusted Cox proportional hazards models reveal urban patients showed increased odds for RPLND overall (OR= 1.10 (1.04-1.17), p=0.002) and uninsured patients having the lowest odds overall for all stages (OR= 0.72 (0.65-0.80), p<0.001).  In multivariable models, distance to treating facility was positively associated with RPLND (OR= 1.10 (1.07-1.13), p<0.001) and patients residing >50 miles from their treatment facility showing the highest odds of RPLND (OR= 4.34 (4.12-4.57), p<0.001). Residents of rural areas had the highest mortality risk within 5–10 years and >10 years following diagnosis (OR= 2.81 (2.06-3.85) and OR= 1.75 (1.47-2.07), p<0.001 (both), respectively).

Conclusion:

This study emphasizes the role demographic, socioeconomic, and geographic considerations play in predicting mortality outcomes for patients with testis cancer. Our data suggests that based on patient geographic area of residence, rural patients and those with the greatest distance traveled have worse outcomes and may require continued surveillance past the 5-year timeline suggested by current guidelines. Our findings underscore the need for outreach and collaboration with local providers to refer suspicious testicular masses for earlier urologic evaluation and continued monitoring.

Funding: N/A