EUROPEAN UROLOGY 60 (2011) 374–379

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Testis Cancer

Global Trends in Testicular Cancer Incidence and Mortality

Alexandre Rosen *, Gautam Jayram, Michael Drazer, Scott E. Eggener

Section of Urology, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA

Article info Abstract

Article history: Background: Epidemiologic studies on testicular cancer have focused primarily on
Accepted May 2, 2011 European countries. Global incidence and mortality have been less thoroughly
Published online ahead of evaluated.
print on May 17, 2011 Objective: Our goal was to gain a better understanding of the most recent global
age-standardized incidence and mortality rates for testicular cancer and to use
Keywords: these values to estimate a region’s health care quality.
Testicular cancer Design, setting, and participants: Age-standardized incidence rate (ASIR) and age-
Incidence standardized mortality rate (ASMR) for testicular cancer were obtained for men of
Mortality all ages in 172 countries by using the GLOBOCAN 2008 database, reflecting the
Epidemiology annual rate of cancer incidence and mortality per 100 000 men. These data were
evaluated on a regional level to compare incidence and mortality rates. Global plots
of these values were constructed to better visualize geographic distributions.
Finally, the ratio of ASIR to ASMR was calculated as a method to assess each
region’s proficiency in diagnosing and effectively treating testicular cancer.
Measurements: ASIR and ASMR were analyzed by region, and each region’s ratio of
ASIR to ASMR was calculated.
Results and limitations: Testicular cancer ASIR is highest in Western Europe (7.8%),
Northern Europe (6.7%), and Australia (6.5%). Asia and Africa had the lowest
incidence (<1.0%). ASMR was highest in Central America (0.7%), western Asia
(0.6%), and Central and Eastern Europe (0.6%). Mortality was lowest in North
America, Northern Europe, and Australia (0.1–0.2%). The ASIR–ASMR ratio was
highest in Australia (65.0%) and lowest in western Africa (1.0%). National reporting
systems varied by country, and data quality may have fluctuated between regions.
Conclusions: Testicular cancer incidence remains highest in developed nations
with primarily Caucasian populations. Variable ASIR–ASMR ratios suggest marked-
ly different geographic-specific reporting mechanisms, access to care, and treat-
ment capabilities.
# 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. 111 S Morgan St, #514, Chicago, IL 60607, USA. Tel. +312 339 9609;
Fax: +312 733 5953.
E-mail address: alexandre.rosen@uchospitals.edu (A. Rosen).

1. Introduction cases diagnosed in 2010 [1]. If left untreated, the natural

course of testicular cancer is metastasis and eventual
In the United States, testicular cancer remains the most mortality. Advances in multimodal treatments (surgery,
common cancer of men aged 15–44, with an estimated 8400 chemotherapy, and radiation) have made the disease one of
0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2011.05.004
 EUROPEAN UROLOGY 60 (2011) 374–379
the most curable cancers, particularly when the diagnosis is
made early in the clinical course. The estimated 5-yr
mortality rate among all patients with testicular cancer, for
example, is 4% in the United States [1].
Recent studies have documented an increase in testis
cancer incidence over the past 40 yr [1–3]. Age-period-cohort
studies focusing on European nations have shown that testis
cancer follows a birth-cohort pattern, meaning an individu-
al’s risk is largely a function of the era in which he was born
[1,4,5]. Additionally, immigrant studies and national cancer
registries have documented remarkably different incidence
rates of testis cancer across geographic areas, with immi-
grants retaining their original region’s testis cancer incidence
rate despite geographic relocation [6–9]. The geographic and
ethnic disparities have led to attempts at delineating
testicular cancer causal factors including genetic predisposi-
tion, maternal estrogen exposure, occupational hazards,
dietary intake composition, smoking habits, and birthplace
[9–21]; however, the most established risk factor remains
cryptorchidism [10,11,22,23].
Testicular cancer incidence and mortality have a distinct
geographic distribution, with Northern and Western Europe
possessing the highest incidence rates [1,2]. Thus testis
cancer epidemiology studies have focused primarily on
European cohorts, whereas global incidence and mortality
have been less thoroughly evaluated. Previous studies
investigating global testis cancer incidence utilizing Cancer
Incidence in Five Continents data from 1973 to 2002
revealed the highest incidence rates in predominantly
Caucasian regions, particularly Europe and North America
(8–9.6 cases per 100 000 man-years), whereas Asia and
Africa had incidence rates of approximately one-tenth of
these values [24,25]. Global testis cancer mortality has been
investigated as a surrogate to health care system quality
utilizing international registry data from the 1960 s to the
1990 s, revealing 5-yr patient survival rates that have
improved with advances in medical therapy and a country’s
economic status [26]. Trend analysis of testicular cancer
mortality has demonstrated that most, but not all, European
countries continued to experience a decrease in mortality
rates from 1990 to 2004 [27]. The work presented in this
paper investigates the current global distribution of both
testicular cancer incidence and mortality by utilizing the
GLOBOCAN database, an international registry estimating
incidence and mortality for all cancers in 172 countries.
2. Material and methods
The GLOBOCAN database is a project engineered by the International
Agency for Research on Cancer (IARC), a subdivision of the World Health
Organization (WHO). The database estimates incidence and mortality
worldwide for the 27 most common cancers [6]. Incidence data are
derived from population-based registries, with the Cancer Incidence in
Five Continents data providing the strongest influence. Mortality data
are derived from WHO statistics originating from national death
registries and provisional estimates for countries without such regis-
tries. Estimates were made by applying the most recently available
disease rates to the corresponding country’s population. The quality of
incidence and mortality data varies greatly by country, and many
countries either have no registry system in place or record incidence and
375
mortality data only in selected regions (eg, large cities). GLOBOCAN
acquires and extrapolates information in a hierarchical fashion with
national registries receiving top priority. With respect to incidence data,
national registries received top priority. If a national registry was
unavailable, regional rates were utilized as a second-line alternative. In
these instances, GLOBOCAN formulated generalized national data from
weighted averages of regional data. Thirteen countries had incidence
data that were unavailable or ‘‘lacking sufficient accuracy.’’ For these
countries, estimates based on the incidence of all cancers combined were
partitioned based on the relative frequency of each cancer type. For 34
countries, no useful incidence data were available, and national
estimates were based on the data of the surrounding countries. With
regard to mortality data, national registries again received top priority
and were available in 65 countries. Sample mortality data were available
in 31 countries that lacked a national registry. In these situations, the
sample data were generalized to a national level. Eighty-eight countries
had no vital mortality statistics and thus had mortality estimated from
incidence [6].
Age-standardized ratios for testicular cancer incidence and mortality
were obtained using the GLOBOCAN 2008 database for men of all ages in
172 countries. These values reflect the estimated annual rate of cancer
incidence and mortality per 100 000 men. The ratio of age-standardized
incidence rate (ASIR) to age-standardized mortality rate (ASMR) was
calculated as a surrogate to assess each country’s proficiency in
diagnosing and effectively treating testicular cancer. Geographic plots
of ASIR–ASMR ratios were constructed to visualize distributions of
incidence and mortality.
3. Results
Testicular cancer incidence is greatest in Western Europe
(7.8%), Northern Europe (6.7%), Australia (6.5%), and North
America (5.1%). Southern Europe and Central America
displayed slightly lower ASIRs of 4.2% and 3.7%, respective-
ly. The lowest ASIRs were found in Asia (0.5–1.5%) and
Africa (0.2–0.7%) (Fig. 1). The geographic distributions are
plotted in Figure 2.
Mortality distribution by region showed the highest
rates for Central America (0.7%), Central and Eastern Europe
(0.6%), and western Asia (0.6%). The lowest mortality rates
were found in Australia (0.1%) and eastern Asia (0.1%).
North America and the remainder of Europe had ASMR
values between these extremes (0.2–0.4%) (Fig. 3). The
geographic distributions are plotted in Figure 4.
The calculated ASIR–ASMR ratios are shown in Figure 5.
ASIR–ASMR ratios were highest in developed, predomi-
nantly Caucasian areas, particularly Europe, North America,
and Australia (range: 14.0–65.0%). Within Europe, distinct
regional differences were observed (Western: 39.0%;
Northern: 25.5%; Southern: 14.0%; Central and Eastern:
4.3%). The lowest ratios were observed in south-central Asia
(2.0%) and Africa (1.0–2.0%).
4. Discussion
Incidence and mortality are important epidemiologic
factors in assessing the burden of a disease on individuals
in a society. The ratio between standardized incidence and
mortality can serve as a surrogate for an individual
country’s ability to effectively diagnose and treat the
disease. Higher ratios suggest that the vast majority of
376 EUROPEAN UROLOGY 60 (2011) 374–379
[()TD$FIG]

Fig. 1 – Incidence rates of testicular cancer (per 100 000) age standardized to the world population.

subjects with the disease survive, whereas low ratios
indicate the opposite. One must use caution, however, when
generalizing global incidence and mortality rates because
the quality of regional data is not consistent.
When taken from a global perspective, testicular cancer
incidence and mortality vary greatly by geographic region.
Australia, North America, and Europe have the highest
overall incidence yet have relatively low mortality, indicat-
ed by the highest ASIR–ASMR ratios. In these regions, ASIR–
ASMR ratios >10% may signify prompt diagnosis and
staging followed by effective multimodal treatment and
surveillance. ASIR–ASMR ratios were lowest in developing
and non-Caucasian countries, primarily in Africa and Asia.
Although these areas had the lowest overall incidence, the
mortality rates roughly equaled the incidence rates,
suggesting that most patients die from their disease
(ASIR–ASMR: 1.0%). One possible explanation is that these
regions possess suboptimal health care systems, leading to
delay in diagnosis and lack of effective multimodal
treatment [28]. Huyghe et al demonstrated that diagnostic
delay is correlated with more advanced disease stage at the
time of diagnosis and reduced 5-yr survival in patients with
nonseminomatous germ cell tumors [29]. Due to the
increased mortality associated with delayed diagnosis, a
region’s ASMR would be increased, thus lowering the
respective ASIR–ASMR value. Even in areas such as Europe
with a high disease incidence overall, significant geographic
variation exists in ASIR–ASMR ratios (Western Europe:

[()TD$FIG]

Fig. 2 – Global geographic distribution of testicular cancers by age-standardized incidence rate (ASIR; per 100 000).
 EUROPEAN UROLOGY 60 (2011) 374–379 377
[()TD$FIG]

Fig. 3 – Mortality rates of testicular cancer (per 100 000) age standardized to the world population.

39.0%; Central and Eastern Europe: 4.3%). This disparity
potentially reveals an asymmetric distribution of testis
cancer awareness and treatment within neighboring
regions; however, regional differences in the incidence
and mortality data collection and reporting systems may
also be responsible for these variations.
Limitations of our study should be considered when
interpreting the data. The GLOBOCAN database seeks to
quantify the world incidence and mortality for 172
countries using the ‘‘best source available’’; however, the
quality and consistency of these sources are difficult to
assess and compare. Furthermore, incidence and mortality
data in underdeveloped nations are often missing, requiring
extrapolation from regional populations within the country
or from neighboring countries; therefore, ASIR and ASMR
may not accurately reflect the true incidence and mortality
for these countries. One must exercise caution when
attempting to draw conclusions based on these data,
particularly for underdeveloped countries that lack national
registries. A trend analysis in the changes in testicular
cancer incidence and mortality over time would be
particularly interesting, but such an analysis is not feasible
using the GLOBOCAN data. Comparison of GLOBOCAN
registries is discouraged by the IARC due to variations in the
availability and quality of cancer registries as well as
improvements in estimation methods from one generation
of the database to the next. Therefore, previous generations
of GLOBOCAN databases cannot be used reliably to
investigate trends in testicular cancer incidence and
mortality. Socioeconomic data analysis for various global

[()TD$FIG]

Fig. 4 – Global geographic distribution of testicular cancers by age-standardized mortality rate (ASMR; per 100 000).
378 EUROPEAN UROLOGY 60 (2011) 374–379
[()TD$FIG]
Fig. 5 – Incidence to mortality ratios of testicular cancer derived from age-standardized rates.
regions was not performed because perceived relationships
would not necessarily demonstrate causation.
5. Conclusions
Testicular cancer incidence remains highest in developed
nations with primarily Caucasian populations. Countries
with a particularly high incidence were more likely to have
relatively low mortality rates. This finding translated into
higher ASIR–ASMR ratios, potentially indicating better
treatment and disease survival in these regions; however,
the quality of regional incidence and mortality data varies
widely and may strongly influence the ASIR–ASMR ratios.
The perceived geographic disparities in ASIR, ASMR, and
ratio of ASIR to ASMR may be due to these quality variations
and may not truly reflect differences in quality of care. In
summary, significant global differences in calculated ASIR–
ASMR ratios suggest marked differences in the quality of
geographic-specific epidemiologic reporting mechanisms,
disease presentation patterns, access to appropriate care,
and treatment capabilities for testicular cancer.
Author contributions: Alexandre Rosen had full access to all the data in the
study and takes responsibility for the integrity of the data and the accuracy
of the data analysis.
Study concept and design: Rosen, Eggener, Drazer.
Acquisition of data: Rosen, Drazer.
Analysis and interpretation of data: Rosen, Eggener, Jayram.
Drafting of the manuscript: Rosen.
Critical revision of the manuscript for important intellectual content: Rosen,
Jayram, Eggener.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: None.
Supervision: Eggener.
Other (specify): None.
Financial disclosures: I certify that all conflicts of interest, including
specific financial interests and relationships and affiliations relevant to the
subject matter or materials discussed in the manuscript (eg, employment/
affiliation, grants or funding, consultancies, honoraria, stock ownership or
options, expert testimony, royalties, or patents filed, received, or pending),
are the following: None.
Funding/Support and role of the sponsor: None.
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