EUROPEAN UROLOGY 65 (2014) 1107–1108
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 1095–1106 of this issue
Epidemiological Studies Are Important to Trigger Health Care Decisions Peter Albers * Department of Urology, Du¨sseldorf University, Du¨sseldorf, Germany
Epidemiological studies on country-specific incidence and mortalities in cancer are important and usually have great impact on local health care politics. However, exact data, especially for incidence rates, are very hard to get and are dependent on the quality of the registries. The article by Znaor et al. in this month’s European Urology gives a valuable overview of incidence and mortality for testicular cancer in 41 countries worldwide [1]. Complete registries were available for data acquisition in only 25 of those countries. Unfortunately, some of the countries with high to very high incidence rates (eg, the United States, France, Germany, and Spain) were able to provide only regional registries, and data had to be extrapolated. Therefore, the incidence data must be interpreted with caution. Because of high absolute numbers, the trends and calculations should nevertheless be valid. In any case, the increase in incidence—especially in developing countries and regions such as South America—is certainly another hint that environmental factors such as exogenous estrogen overexposure during pregnancy and endocrine-disrupting chemicals such as organochlorine pesticides contribute to testicular cancer genesis [2–4]. However, as opposed to availability of treatment, environmental factors usually cannot be changed rapidly. The quality of mortality data is usually better. In contrast to the sometimes difficult problem of evaluating the exact cause of death in older patients, the death certificates of patients dying of testicular cancer—usually at a very young age—are reliable. There are mainly two reasons why men die of testicular cancer: (1) The disease was detected at a very advanced stage and the individual already had multiple organ failures at the beginning of
treatment or (2) the disease was refractory to treatment because of its aggressive biology. In both instances, treatment failures contribute to a higher-than-expected death rate as well. Both a reduction in the delay of detection and effective treatment of refractory tumors depend on local health care structures and adherence to guidelines [5]. In rural areas and countries with a lower Human Development Index, medical knowledge among patients and uro-oncologic expertise in a multidisciplinary setting are lacking. I know countries in central and eastern Europe in which urologists are able to use only surgery for the treatment of advanced disease in seminoma and nonseminoma because of the nonavailability of modern chemotherapy drugs or radiotherapy or both. These differences in health care structures are responsible for the differences in mortality rates among countries and can potentially be changed. The paper of Znaor et al. [1] nicely describes these disadvantages by indirect proof of higher mortality rates, especially in those countries we all know have inferior health care structures. The European Union has an obligation to support the improvement of those structures while expanding eastward. The European Association of Urology understood this obligation many years ago and constantly provides colleagues in the eastern parts of the European Union with knowledge and guidelines for treatment in the interest of their patients. The availability of drugs and structures, however, can be improved only by publishing epidemiological papers that show that countries with very high incidence rates are able to achieve the lowest mortality rates through standardized treatment, specialist training, interdisciplinary clinics, and proper equipment
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.11.004. * Department of Urology, Du¨sseldorf University, Moorenstr. 5, Du¨sseldorf, 40225 Germany. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.11.032
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(eg, stem cell support for high-dose chemotherapy regimens). These countries then might reduce their treatment burden by better classifying patients with testicular cancer. This advancement will lead not only to a steady, low mortality rate but also to testicular cancer survivors who will be healthy and thereby can contribute to their societies as healthy individuals. Thus, epidemiological papers should be used as political arguments to improve health care structures, education, knowledge, and technical equipment in countries that have high incidence and high mortality rates. And in these countries, this proposition probably applies to far more than just testicular cancer.
References [1] Znaor A, Lortet-Tieulent J, Jemal A, Bray F. International variations and trends in testicular cancer incidence and mortality. Eur Urol 2014;65:1095–106. [2] Weir HK, Marrett LD, Kreiger N, Darlington GA, Sugar L. Pre-natal and peri-natal exposures and risk of testicular germ-cell cancer. Int J Cancer 2000;87:438–43. [3] Sonke GS, Chang S, Strom SS, Sweeney AM, Annegers JF, Sigurdson AJ. Prenatal and perinatal risk factors and testicular cancer: a hospital-based case-control study. Oncol Res 2007;16:383–7. [4] McGlynn KA, Quraishi SM, Graubard BI, Weber JP, Rubertone MV, Erickson RL. Persistent organochlorine pesticides and risk of testicular germ cell tumors. J Natl Cancer Inst 2008;100:663–71. [5] Albers P, Albrecht W, Algaba F, et al. Guidelines on testicular cancer. European Association of Urology Web site. http://uroweb.org/gls/
Conflicts of interest: The author has nothing to disclose.
pdf/Testicular%20Cancer%202010.pdf. 2010.
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Platinum Priority – Editorial Referring to the article published on pp. 1095–1106 of this issue
Epidemiological Studies Are Important to Trigger Health Care Decisions Peter Albers * Department of Urology, Du¨sseldorf University, Du¨sseldorf, Germany
Epidemiological studies on country-specific incidence and mortalities in cancer are important and usually have great impact on local health care politics. However, exact data, especially for incidence rates, are very hard to get and are dependent on the quality of the registries. The article by Znaor et al. in this month’s European Urology gives a valuable overview of incidence and mortality for testicular cancer in 41 countries worldwide [1]. Complete registries were available for data acquisition in only 25 of those countries. Unfortunately, some of the countries with high to very high incidence rates (eg, the United States, France, Germany, and Spain) were able to provide only regional registries, and data had to be extrapolated. Therefore, the incidence data must be interpreted with caution. Because of high absolute numbers, the trends and calculations should nevertheless be valid. In any case, the increase in incidence—especially in developing countries and regions such as South America—is certainly another hint that environmental factors such as exogenous estrogen overexposure during pregnancy and endocrine-disrupting chemicals such as organochlorine pesticides contribute to testicular cancer genesis [2–4]. However, as opposed to availability of treatment, environmental factors usually cannot be changed rapidly. The quality of mortality data is usually better. In contrast to the sometimes difficult problem of evaluating the exact cause of death in older patients, the death certificates of patients dying of testicular cancer—usually at a very young age—are reliable. There are mainly two reasons why men die of testicular cancer: (1) The disease was detected at a very advanced stage and the individual already had multiple organ failures at the beginning of
treatment or (2) the disease was refractory to treatment because of its aggressive biology. In both instances, treatment failures contribute to a higher-than-expected death rate as well. Both a reduction in the delay of detection and effective treatment of refractory tumors depend on local health care structures and adherence to guidelines [5]. In rural areas and countries with a lower Human Development Index, medical knowledge among patients and uro-oncologic expertise in a multidisciplinary setting are lacking. I know countries in central and eastern Europe in which urologists are able to use only surgery for the treatment of advanced disease in seminoma and nonseminoma because of the nonavailability of modern chemotherapy drugs or radiotherapy or both. These differences in health care structures are responsible for the differences in mortality rates among countries and can potentially be changed. The paper of Znaor et al. [1] nicely describes these disadvantages by indirect proof of higher mortality rates, especially in those countries we all know have inferior health care structures. The European Union has an obligation to support the improvement of those structures while expanding eastward. The European Association of Urology understood this obligation many years ago and constantly provides colleagues in the eastern parts of the European Union with knowledge and guidelines for treatment in the interest of their patients. The availability of drugs and structures, however, can be improved only by publishing epidemiological papers that show that countries with very high incidence rates are able to achieve the lowest mortality rates through standardized treatment, specialist training, interdisciplinary clinics, and proper equipment
DOI of original article: http://dx.doi.org/10.1016/j.eururo.2013.11.004. * Department of Urology, Du¨sseldorf University, Moorenstr. 5, Du¨sseldorf, 40225 Germany. E-mail address: [email protected]. 0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.11.032
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EUROPEAN UROLOGY 65 (2014) 1107–1108
(eg, stem cell support for high-dose chemotherapy regimens). These countries then might reduce their treatment burden by better classifying patients with testicular cancer. This advancement will lead not only to a steady, low mortality rate but also to testicular cancer survivors who will be healthy and thereby can contribute to their societies as healthy individuals. Thus, epidemiological papers should be used as political arguments to improve health care structures, education, knowledge, and technical equipment in countries that have high incidence and high mortality rates. And in these countries, this proposition probably applies to far more than just testicular cancer.
References [1] Znaor A, Lortet-Tieulent J, Jemal A, Bray F. International variations and trends in testicular cancer incidence and mortality. Eur Urol 2014;65:1095–106. [2] Weir HK, Marrett LD, Kreiger N, Darlington GA, Sugar L. Pre-natal and peri-natal exposures and risk of testicular germ-cell cancer. Int J Cancer 2000;87:438–43. [3] Sonke GS, Chang S, Strom SS, Sweeney AM, Annegers JF, Sigurdson AJ. Prenatal and perinatal risk factors and testicular cancer: a hospital-based case-control study. Oncol Res 2007;16:383–7. [4] McGlynn KA, Quraishi SM, Graubard BI, Weber JP, Rubertone MV, Erickson RL. Persistent organochlorine pesticides and risk of testicular germ cell tumors. J Natl Cancer Inst 2008;100:663–71. [5] Albers P, Albrecht W, Algaba F, et al. Guidelines on testicular cancer. European Association of Urology Web site. http://uroweb.org/gls/
Conflicts of interest: The author has nothing to disclose.
pdf/Testicular%20Cancer%202010.pdf. 2010.
