Care Plans for Testicular Cancer Survivors Should Anticipate Late Effects of Chemo

New research shows that survivors of testicular cancer may face an increased vulnerability to additional health problems after being treated with cisplatin-based chemotherapy, and suggests that survivorship care should be informed by that risk.

This burden of morbidity, or likelihood of developing new health problems, also increased with age and had a negative impact on self-perception of health, according to a study presented by Sarah L. Kerns at the 2016 Cancer Survivorship Symposium in San Francisco.

Most men with testicular cancer are diagnosed at a young age, and while the disease is highly curable with a 10-year survival rate of more than 95 percent, this population is vulnerable to future health conditions.

“Despite this excellent long-term survival profile, testicular cancer survivors are at risk for late adverse effects from treatment for many decades — most of their adult life,” said Kerns, a research assistant professor in the Department of Radiation Oncology at the University of Rochester. “This really represents an important population in which to study late effects of cancer; in particular, cisplatin-based chemotherapy effects on health outcomes.”

The study evaluated 751 participants under age 50 at the time of their diagnosis who underwent cisplatin-based chemotherapy.

The survivors answered questionnaires about health outcomes and prescription drug use. Outcomes were mapped and graded for severity using the the NCI Common Terminology Criteria for Adverse Events (CTCAE) v4.03. Grade 0 was categorized as no adverse effects, and grade 4 encompassed the most severe adverse effects.

Obesity was the most commonly reported health outcome (74 percent), followed by peripheral sensory neuropathy, or nerve damage that can cause a loss of sensation in parts of the body not near the brain or spinal cord (63 percent); peripheral motor neuropathy, or nerve damage that can cause muscle weakness and/or cramping (45 percent); tinnitus, a ringing in the ears (45 percent); hearing loss (44 percent); and erectile dysfunction (29 percent).

“Obesity was by far the most frequent, and this likely reflects national trends in obesity rates in the United States as well as the effects of cisplatin, which is known to affect symptoms of metabolic syndrome,” Kerns said.

Considering the frequency and severity of each outcome, a cumulative burden of morbidity (CBM) was then derived. An increase in number and severity of health outcomes contributed to an increased CBM score.

Nearly 70 percent of testicular cancer survivors had a CBM score of medium, which was defined as at least one grade 2 health outcome or one grade 3 outcome. Twenty percent of survivors had a high CBM, defined by multiple grade 3 outcomes.Only 2.5 percent reported having no adverse health outcomes, 8.3 percent had at least one grade 1 outcome and 0.5 percent had a severe CBM score.

Older age was associated with increased odds of having a worse CBM score, and an increasing CBM score was associated with a negative impact on self-perceived health. The authors noted that this finding shows that survivors perceive health conditions following chemotherapy as negatively impacting their health in survivorship.

Of the participants, 62.5 percent had received bleomycin, etoposide and cisplatin (BEP), and about one-third had received etoposide and cisplatin (EP).

Each 100 mg/m² increase in cisplatin was associated with a worse CBM score when restricted to outcomes related to cisplatin exposure, including peripheral sensory neuropathy, hearing loss, tinnitus, vertigo, vestibular disorder and chronic kidney disease.

The average time since chemotherapy at the point of evaluation was about five years; for only about 20 percent of participants had more than 10 years elapsed since their last chemotherapy.

Kerns added that her study may underestimate morbidity, since most of the participants may not have been at risk long enough to develop some late health outcomes.

Additionally, the cross-sectional design of the study does not allow for an establishment of a causal relationship between CBM score and cisplatin-based chemotherapy exposure.

The researchers concluded that future research should focus on defining validated measures to evaluate long-term CBM among survivors of testicular cancer and eventually develop risk-adapted survivorship care plans.