Low Socioeconomic Status is a Risk Factor for Delay to Treatment and Mortality of Testicular Cancer Patients in Hungary. A Prospective Study

Low Socioeconomic Status is a Risk Factor for Delay to Treatment and Mortality of Testicular Cancer Patients in Hungary. A Prospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Low Socioeconomic Status is a Risk Factor for Delay to Treatment and Mortality of Testicular Cancer Patients in Hungary. A Prospective Study Zsófia Küronya, Georgina Fröhlich, Andrea Ladányi, Tamás Martin, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-273912/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background . In Hungary, the mortality rate for testicular germ cell cancer (TGCC) is 7.6% which is significantly higher than the EU average. We prospectively evaluated the effect of socioeconomic status on patient delay, doctor’s delay, and therapy outcomes. Methods: Questionnaires on subjective (MacArthur Subjective Status Scale), objective (wealth, education, and housing data) social status, and on patient’s and doctors’ delays were completed by newly diagnosed TGCC patients. Results: Patients belonged to a relatively high socioeconomic class, a university degree was double the Hungarian average, Cancer-specific mortality in the highest social quartile was 1.56% while in the lowest social quartile 13.09% (p=0.02). In terms of patient delay, 57.2% of deceased patients waited more than a year before seeking help, while this number for the surviving patients was 8.0% (p=0.0000). Longer patient delay was associated with a more advanced stage in non-seminoma but not in seminoma, the correlation coefficient for non-seminoma was 0.321 (p<0.001). For patient delay, the most important variables were the mother’s and patient’s education levels (r=-0.21, p=0.0003, and r=-0.20, p=0.0005), respectively. Since the patient delay was correlated with the social quartile and resulted in a more advanced stage in non-seminoma, the lower social quartile resulted in higher mortality in non-seminoma patients (p=0.005) but not in seminoma patients (p=0.36) where the patient delay was not associated with a more advanced stage. Conclusions: Based on our result, we conclude that to improve survival, we should promote testicular cancer awareness, especially among the most deprived populations, and their health care providers. Health Economics & Outcomes Research Infectious Diseases Health Policy testicular cancer socioeconomic status patient delay doctor’s delay Figures Figure 1 Figure 2 Background Malignant testicular germ cell cancer (TGCC) is relatively uncommon, however, this is still the leading type of cancer in men between the ages of 20 and 40 years. [ 1 ] Due to huge improvements in imaging and chemotherapy, mortality rates in patients with testicular cancer have declined in recent decades. In the most affluent world regions, while rapid increases in incidence rates have been observed lately, the mortality rates declined to 0.2–0.3 per 100,000. However, in Central and Eastern European (CEE) countries (i.e., Bulgaria, Czech Republic, Hungary, Poland, Romania, and Slovakia), rates have only moderately declined and were still 1.3/100,000[ 2 ][ 3 ][ 4 ] for men aged between 20 and 44 years in 1995–1997. In the first decade of the 2000s, a significant decline in testicular cancer patients’ mortality rates appeared also in CEE countries, but the ratio is still higher than in the more developed EU members. [ 5 ] According to a WHO database, Hungary and Latvia had the worst TGCC mortality rate in Europe (0.9/100,000) between 2000 and 2006.[ 6 ]. The slower and delayed declines in the less developed, lower resource countries imply that the high cost of appropriate treatments together with inadequate patient referral systems are responsible for the high mortality rates and less favorable trends. Another factor of the slower progress may partly relate to differences in socioeconomic status (SES), i.e. men with lower SES may be characterized by a lack of awareness and maybe less likely to seek immediate medical help, moreover, they tend to have the worst access to medical service, particularly in rural and remote communities. There is extensive literature describing SES differences and cancer survival in countries around the world in various health care systems. [ 7 ][ 8 ][ 9 ][ 10 ] The authors of this report prospectively evaluated the effects of subjective social status (SSS) on delay to diagnosis, stage distribution, and cancer-specific mortality (CSM) in men with TGCC. The studied patient cohort was treated at the National Institute of Oncology GU department, which is the main germ cell cancer center in Hungary, treating roughly 60% of the approximately 600 Hungarian TGCC patients yearly. The aim of this research was to investigate how the patients’ socioeconomic status affects the time elapsed between onset of symptoms and diagnosis, and therapy outcome. Methods 2.1. Ethical statement This prospective, non-interventional study was carried out between January 2016 and January 2018, at the National Institute of Oncology. The database lock occurred in September 2019. The study was performed in accordance with Hungarian laws and regulations and was approved by the Hungarian National Scientific Ethical Committee (approval number: 44476-2/2016), and as per the standards of the World Medical Association Declaration of Helsinki. All patients who were willing to participate signed informed consent. 2.2. Study population Inclusion criteria included male patients over 16 years old (inclusive), with newly diagnosed testicular cancer with a gonadal onset. Clinical stage and prognosis were determined according to the Union for International Cancer Control (UICC), [ 11 ] and the International Germ Cell Cancer Collaborative Group (IGCCCG) [ 12 ] based on the pathology report, the tumor marker (AFP, HCG, LDH) level, and the CT scan. Castration was the first-line treatment for the majority of patients (Table 1), followed by surveillance or adjuvant chemotherapy (St I), or by multiple cycles of platinum-based chemotherapy, and salvage surgery where needed (St II-III). In 16 patients whose conditions related to metastatic dissemination required immediate chemotherapy, orchiectomy was postponed until the completion of chemotherapy. Patients received the internationally recognized standard of care, based on the current European Society for Medical Oncology (ESMO) guideline.[ 13 ] 2.3 Assessment of the objective and subjective socioeconomic status The subjective social status (SSS) and objective socioeconomic status (SES) questionnaires were completed on the first consultation visit of newly diagnosed TGCC patients. The SSS was determined based on the MacArthur Scale of Subjective Status questionnaire. After the owner’s written permission for usage and linguistic validation, the questionnaire has been translated into Hungarian and was adapted for this study. MacArthur scale is a social or community hierarchy ladder used by the patients based on their deemed place; with values of 1–10. [ 14 ][ 15 ][ 16 ][ 17 ] We measured two variables: social status, and community status value (Fig. 1). For objective SES patient’s highest educational attainment, residency, income, possession of consumer durable goods, occupational class, and the parents’ highest educational level were evaluated. An index number was created based on the educational level, the number of consumer durable goods, and the size of living area per capita. Based on this index number, patients were divided into 4 quartiles. The first quartile was the lowest, with the poorest status and lowest educational level. The section on illness comprised of questions including the time gap between the first symptoms and visiting a doctor (patient delay, PD), and between the first doctor’s visit and first consultation at our institute (doctor’s delay, DD). Histology, stage, and treatment outcome were extracted from the patient database. 2.4. Statistical analyses Statistical analyses were performed using SPSS 22.0 (IBM Corp.) and Statistica 12.5 (StatSoft, Tulsa, OK, USA). To detect the association between the doctor’s delay and overall survival (OS) Mann-Whitney U test was used while the correlation between the patient’s delay and survival was determined by logistic regression. To examine the effect of SES on survival Fisher exact test was carried out. The association between various patient characteristics and OS were analyzed by Kaplan-Meier analysis. To examine the correlation between patient education and PD, and between SSS and SES, Spearman rank correlation was performed. Results were considered significant at p values lower than 0.05. Results 3.1. Patient characteristics Altogether, 306 patients filled out the questionnaire. Analyses were performed on 303 patients who met the inclusion criteria (3 cases with non-gonadal origin were excluded from the analysis). The patients’ mean age was 35.9 years (seminoma 38.5, non-seminoma 33.1) (Table 2). The mother’s mean age at childbirth was 26 years whilst the father’s mean age at childbirth was 29.1 years. Patients belonged to a relatively high socioeconomic class, 103 (34%) patients had a university or college degree, which is twice as many as the Hungarian society average. [ 18 ] SSS among patients was 5.57 ± 1.70 while the Hungarian average among males in this age group is 3.97 ± 0.03 (out of 10). [ 19 ]. Fourteen patients died during the study period, they were significantly older than the surviving patients, 41.6 vs. 35.9 years (p = 0.0277) (Table 1). Among patients with metastatic seminoma 152 (98.7%) belonged to the good and 2 (1.3%) to the intermediate prognostic group, while among those with non-seminoma 116 (77.9%), 12 (8.0%), and 21 (14.1%) belonged to good, intermediate and poor prognostic group, respectively. Table 3 shows the stage distribution among seminoma and non-seminoma patients. The majority of patients belonged to stage I (seminoma: 71.5% and non-seminoma 47.6%), though a higher proportion of non-seminoma patients had metastatic disease (StII/StIII) at diagnosis (28.5% seminoma vs. 52.4% non-seminoma). 3.2. Objective and subjective social status Regarding patients’ residence type, distance from the National Institute of Oncology, number of household members, number of members with income, and internet usage frequency there was no difference between the seminoma and non-seminoma group (Table 2). Table 4 presents social quartiles based on objective social status and the distribution of SSS. The distribution of SSS was normal (Table 4). The full range of score distribution (1–10) was observed. The mean SSS value for the entire sample was 5.57 ± 1.70, while the median and mode coincided between the fifth and sixth rung. In terms of SSS, there was also no difference between seminoma and non-seminoma patients (p = 0.7898). 3.3. Patients’ objective versus subjective self-grade values The patient’s SSS was compared to the SES indicators. Both the social ladder value and the community ladder value exhibited a significant correlation with the objective socioeconomic status-based quartiles (r = 0.508 and r = 0.417, respectively, p < 0.001). 3.4. Factors associated with patient’s delay and doctor’s delay The diagnostic time path was from within 1 week to over 1 year, with the ‘1 week-1 month’ being the median (102 patients). We found a negative correlation between the father’s education and patient delay (PD) (r=-0.12, p = 0.0383), and an even stronger negative correlation between the mother’s education and the PD, as well as the patient’s education and the PD (r=-0.21, p = 0.0003, and r=-0.20, p = 0.0005, respectively). Table 5 shows PD based on the educational level of the patients. Both PD and DD negatively correlated with social quartile (r=-0.18, p = 0.0022 and r=-0.15, p = 0.0131, respectively). The social quartile value showed a stronger association with PD than with DD, the latter also correlated with the distance (km) from the National Institute of Oncology (r = 0.12, p = 0.0347). Each PD and DD were significantly longer for deceased patients than for surviving patients (Table 6). 3.5. Patient delay, social quartile, and overall survival Of the 14 patients who died during the study course, 11 (78.6%) were in the social quartile 1 (lowest), compared to 73 of the 289 surviving patients (25.3%) (p < 0.001) (Table 5) Fig. 2 shows the OS based on the social quartile, and PD for all patients and separated for non-seminoma and seminoma patients. 57.2% of deceased patients waited more than a year before seeking help, while this number for the surviving patients was 8.0% (p < 0.001). Longer PD was associated with a more advanced stage in non-seminoma, but not in seminoma patients, the correlation coefficient for NS was 0.321 (p < 0.001) hence PD significantly influenced OS in NS (p = 0.0021) but not in S (p = 0.13) (Fig. 2). Since PD was correlated with social quartile, as mentioned above, and resulted in a more advanced stage in non-seminoma, lower social quartile resulted in higher mortality in NS patients (p = 0.0048) but not in S patients (p = 0.36) where PD was not associated with more advanced stage. Discussion The present study has been conducted at one site (National Institute of Oncology, Department of Genitourinary Medical Oncology and Clinical Pharmacology), between 2016 and 2018, and includes the prospective data analysis of the socioeconomic status of patients followed or treated with testicular cancer. The 303 patients who participated in the study, is approximately half of the yearly Hungarian TGCC incidence (600–650 cases/year). [ 20 ] Inequalities in cancer mortality and morbidity between populations with different (lower and higher) socioeconomic positions are widely described in the literature [ 21 ]. We measured both the subjective (social ladder, SSS) and objective (SES) social status and found that both the social ladder value and the community ladder value exhibited a significant correlation with the objective socioeconomic status-based quartiles. The association between SES and SSS, which is distinctive in different cultural groups, was reported in several papers.[ 22 ] [ 23 ][ 24 ] SSS is easier to use because many people do not want to report their income and education levels. Furthermore, it seems to predict health and general well-being better than objective SES measurements. [ 17 ][ 25 ] In the current study, we found a major deviation in terms of the patient’s highest education level compared to the country averages Those educated to college/university level (34%) were represented 1.5 times more as the Hungarian society averages suggest, while those with the lowest education (8%) have been presented in a significantly lower extent compared to the Hungarian average (27%). [ 18 ] SSS among patients was 5.57 ± 1.70 while the Hungarian average among males in this age group is 3.97 ± 0.03 (out of 10). [ 19 ] Numerous reports indicate that TGCC has for some time tended to occur disproportionately among men of high socioeconomic status and the sons of women of high socioeconomic status [ 26 ][ 27 ], while other reports have not found such associations [ 28 ]. Since both the intensity of treatment and prognosis are based on the extent of disease at presentation, a testicular cancer diagnosis must not be delayed. Among our TGCC patients, PD and DD showed significant relations with social status. In terms of PD, the most influential was the mother’s and patient’s education. Delay in the diagnosis of testicular cancer is well documented [ 29 ][ 30 ][ 31 ][ 32 ]. Dieckmann and colleagues found that PD was related to educational level. College-educated men were found to have shorter mean and median delay [ 33 ] [ 25 ]. The less educated patients may actually believe that a larger testicle makes a more virile man. [ 34 ]. On the other hand, Toklu et al. have not found a correlation between the annual income, the educational level, and the delay to treatment [ 35 ][ 26 ]. Physician-mediated delay most commonly results from the misdiagnosis of a testis tumor as an infection. In one study of 335 testicular cancer patients, one third were treated initially with antibiotics for presumed epididymitis[ 31 ]. In our cohort social quartile value showed a stronger association with PD than with DD, the latter also correlated with the distance (km) from the National Institute of Oncology. There is only a limited reference in the literature to the possible association between the patient’s SES and the stage of their disease. Seminomas can have an indolent growth, and delay in diagnosis usually does not result in a more advanced stage. [ 34 ][ 32 ][ 36 ] Since in our study PD in seminoma patients did not influence the stage, thus the social quartile in seminoma did not determine the survival significantly. For non-seminoma patients, there is a clearer association between delay in diagnosis and advanced disease. [ 30 ] [ 31 ][ 37 ][ 38 ] and the increased delay has also been associated with decreased survival [ 34 ][ 36 ][ 39 ]. PD among our non-seminoma patients presented a more advanced stage, and based on our research, PD was significantly correlated with social status, therefore social quartile and survival also had significant interdependence in non-seminoma patients. In the study of Davies, TGCC patients with lower SES had higher mortality rates. [ 40 ]. Sun et al. reported from their multivariate analysis that low SES groups had significantly higher cancer-related mortality rates, as well as higher collective mortality rates retrospectively.[ 41 ] This was in line with the findings of Davies et al. who reported a higher mortality rate among those educated at the vocational school level.[ 40 ] This has also been proved by the results reported in this research, as 10 out of 14 deceased patients were educated to that level, and 9 out of 10 belonged to the lowest quartile. The number of deceased patients was significantly higher among those who waited at least 1 year before the first doctor visit. According to our knowledge, there is no similar finding, published in our research area. The mortality rate among our patients (4.6%) was better compared to the Hungarian average (7.6%), and this underscores the importance of having the TGCC patients managed in a specialized center, It has been reported earlier that specialist centers demonstrate superior results to nonspecialist centers [ 42 ][ 43 ] Limitation of the study Similar to other studies measuring patient-reported timelines, bias may occur when patients recall the exact delay period. Conclusions To our knowledge, this is the first study that prospectively evaluated the TGCC patients’ objective and subjective social statuses along with survival ratios, all other studies investigated them retrospectively, and indirectly. Mother’s and patient education posed an influent aspect of PD; higher education led to a shorter PD period and hence better survival in non-seminoma patients. Based on our result, we conclude that to improve survival, we should promote testicular cancer awareness, especially among the most deprived populations, and their health care providers. Abbreviations AFP Alpha-fetoprotein CEE Central and Eastern European countries CT Computed tomography CSM Cancer-specific mortality DD Doctor’s delay EU European Union GU Genito-urinary HCG Human chorionic gonadotropin IGCCCG International Germ Cell Cancer Collaborative Group Km Kilometer LDH Lactate dehydrogenase OS Overall survival PD Patient delay SES Socioeconomic status SSS Subjective social status St Stage TGCC Testicular germ cell cancer UICC Union for International Cancer Control WHO World health organization Declarations Author information: Affiliations: National Institute of Oncology, Budapest, Hungary Zsófia Küronya, Georgina Fröhlich, Andrea Ladányi, Tamás Martin, Lajos Géczi, Fruzsina Gyergyai, Orsolya Horváth, Gergő Kiszner, Tamás Dienes, Enikő Lénárt, Krisztián Nagyiványi Krisztina Biró Eötvös Loránd University, Faculty of Science, Budapest, Hungary Georgina Fröhlich, Boehringer Ingelheim RCV GmbH & Co. KG Branch Office Budapest, Hungary Ágnes Kovács Semmelweis University Budapest, Hungary Tibor Szarvas, Mihály Szőnyi Adherencia.net Kft., Budapest, Hungary Attila Tóth Corresponding author: Zsófia Küronya, [email protected] National Institute of Oncology, Department of Genitourinary Medical Oncology and Clinical Pharmacology, Ráth György u. 7-9., Budapest, H-1122, Hungary Contributions: Zs.K, and K.B planned and conducted the research with the help of T.M. Statistical analysis was carried out by G.F and Á.K. The SSS and SES questionnaires were created by A.T. Critical revision was carried out by A.L. All the remaining authors (L.G, F.Gy, O.H, G.K, T. D, E.L, K N.) helped with data collection. All authors have read and approved the manuscript. Ethics approval and consent to participate : The was approved by the Hungarian National Scientific Ethical Committee (approval number: 44476-2/2016),. All patients who were willing to participate signed informed consent. Consent to publication: Not applicable Competing interests We declare that we have no conflict of interest. Funding: Not applicable Availability of data and material The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References [1] F. Bray, J. Ferlay, I. Soerjomataram, R. L. Siegel, L. A. Torre, and A. Jemal, “Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries,” CA. Cancer J. Clin. , vol. 68, no. 6, pp. 394–424, Nov. 2018. [2] F. Bray, L. Richiardi, A. Ekbom, E. Pukkala, M. Cuninkova, and H. Møller, “Trends in testicular cancer incidence and mortality in 22 European countries: Continuing increases in incidence and declines in mortality,” Int. J. Cancer , vol. 118, no. 12, pp. 3099–3111, Jun. 2006. [3] C. Bosetti, P. Bertuccio, L. Chatenoud, E. Negri, C. La Vecchia, and F. Levi, “Trends in mortality from urologic cancers in Europe, 1970-2008,” Eur. Urol. , vol. 60, no. 1, pp. 1–15, Jul. 2011. [4] F. Levi, C. La Vecchia, P. Boyle, F. Lucchini, and E. Negri, “Western and eastern European trends in testicular cancer mortality.,” Lancet (London, England) , vol. 357, no. 9271, pp. 1853–4, Jun. 2001. [5] A. Znaor and F. Bray, “Thirty year trends in testicular cancer mortality in Europe: Gaps persist between the East and West,” Acta Oncol. (Madr). , vol. 51, no. 7, pp. 956–958, Sep. 2012. [6] “WHO Mortality Database - WHO.” [Online]. Available: https://www.who.int/data/data-collection-tools/who-mortality-database. [Accessed: 16-Oct-2020]. [7] A. Rosengren and L. Wilhelmsen, “Cancer incidence, mortality from cancer and survival in men of different occupational classes,” Eur. J. Epidemiol. , vol. 19, no. 6, pp. 533–540, Jun. 2004. [8] G. K. Singh, S. D. Williams, M. Siahpush, and A. Mulhollen, “Socioeconomic, rural-urban, and racial inequalities in US cancer mortality: Part I-All cancers and lung cancer and part II-Colorectal, prostate, breast, and cervical cancers,” J. Cancer Epidemiol. , vol. 2011, 2011. [9] D. Vagero and G. Persson, “Cancer survival and social class in Sweden,” J. Epidemiol. Community Health , vol. 41, no. 3, pp. 204–209, 1987. [10] G. D. Smith, D. Leon, M. J. Shipley, and G. Rose, “Socioeconomic differentials in cancer among men,” Int. J. Epidemiol. , vol. 20, no. 2, pp. 339–345, Jun. 1991. [11] G. M. W. C. Brierley J, Ed., TNM classification of malignant tumours, Eighth edition . John Wiley & Sons, Inc, Chichester, West Sussex, UK ; Hoboken, NJ, 2016. [12] G. M. Mead and S. P. Stenning, “The International Germ Cell Consensus Classification: A new prognostic factor-based staging classification for metastatic germ cell tumours,” Clinical Oncology , vol. 9, no. 4. Elsevier Ltd, pp. 207–209, 1997. [13] J. Oldenburg et al. , “Testicular seminoma and non-seminoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up,” Ann. Oncol. , vol. 24, no. SUPPL.6, 2013. [14] N. E. Adler, E. S. Epel, G. Castellazzo, and J. R. Ickovics, “Relationship of subjective and objective social status with psychological and physiological functioning: Preliminary data in healthy, White women.,” Heal. Psychol. , vol. 19, no. 6, pp. 586–592, 2000. [15] J. M. Ostrove, N. E. Adler, M. Kuppermann, and A. E. Washington, “Objective and subjective assessments of socioeconomic status and their relationship to self-rated health in an ethnically diverse sample of pregnant women.,” Heal. Psychol. , vol. 19, no. 6, pp. 613–618, 2000. [16] E. Goodman, N. E. Adler, I. Kawachi, A. L. Frazier, B. Huang, and G. A. Colditz, “Adolescents’ perceptions of social status: development and evaluation of a new indicator.,” Pediatrics , vol. 108, no. 2, 2001. [17] A. Singh-Manoux, N. E. Adler, and M. G. Marmot, “Subjective social status: Its determinants and its association with measures of ill-health in the Whitehall II study,” Soc. Sci. Med. , vol. 56, no. 6, pp. 1321–1333, Mar. 2003. [18] Bojer A, Erdei V, Vörös C, “(2017) Mikrocenzus 2016, 4. Iskolázottsági adatok.” [19] M. Kopp, Á. Skrabski, J. Réthelyi, I. Kawachi, and N. E. Adler, “Self-rated health, subjective social status, and middle-aged mortality in a changing society,” Behav. Med. , vol. 30, no. 2, pp. 65–72, 2004. [20] “Hungarian National Cancer Registry.” [Online]. Available: http://ghdx.healthdata.org/organizations/national-cancer-registry-hungary-10. [21] “Area Socioeconomic Variations in U.S. Cancer 1975 - 1999 - SEER Publications.” [Online]. Available: https://seer.cancer.gov/archive/publications/ses/. [Accessed: 17-Oct-2020]. [22] K. B. Curhan et al. , “Subjective and Objective Hierarchies and Their Relations to Psychological Well-Being: A U.S./Japan Comparison,” Soc. Psychol. Personal. Sci. , vol. 5, no. 8, pp. 855–864, Nov. 2014. [23] N. Adler, A. Singh-Manoux, J. Schwartz, J. Stewart, K. Matthews, and M. G. Marmot, “Social status and health: A comparison of British civil servants in Whitehall-II with European- and African-Americans in CARDIA,” Soc. Sci. Med. , vol. 66, no. 5, pp. 1034–1045, Mar. 2008. [24] N. Goldman, J. C. Cornman, and M. C. Chang, “Measuring subjective social status: A case study of older Taiwanese,” J. Cross. Cult. Gerontol. , vol. 21, no. 1–2, pp. 71–89, Mar. 2006. [25] J. R. Garza, B. A. Glenn, R. S. Mistry, N. A. Ponce, and F. J. Zimmerman, “Subjective Social Status and Self-Reported Health Among US-born and Immigrant Latinos,” J. Immigr. Minor. Heal. , vol. 19, no. 1, pp. 108–119, Feb. 2017. [26] D. Schottenfeld, M. E. Warshauer, S. Sherlock, A. G. Zauber, M. Leder, and R. Payne, “The epidemiology of testicular cancer in young adults,” Am. J. Epidemiol. , vol. 112, no. 2, pp. 232–246, 1980. [27] A. J. Swerdlow, A. J. Douglas, S. R. A. Huttly, and P. G. Smith, “Cancer of the testis, socioeconomic status, and occupation,” Br. J. Ind. Med. , vol. 48, no. 10, pp. 670–674, 1991. [28] A. Prener, C. cheng Hsieh, G. Engholm, D. Trichopoulos, and O. M. Jensen, “Birth order and risk of testicular cancer,” Cancer Causes Control , vol. 3, no. 3, pp. 265–272, May 1992. [29] J. W. Moul, “Timely Diagnosis of Testicular Cancer,” Urologic Clinics of North America , vol. 34, no. 2. Urol Clin North Am, pp. 109–117, May-2007. [30] J. W. Moul, D. F. Paulson, R. K. Dodge, and P. J. Walther, “Delay in diagnosis and survival in testicular cancer: Impact of effective therapy and changes during 18 years,” J. Urol. , vol. 143, no. 3, pp. 520–523, 1990. [31] G. J. Bosl et al. , “Impact of delay in diagnosis on clinical stage of testicular cancer,” Lancet , vol. 318, no. 8253, pp. 970–973, Oct. 1981. [32] K.-P. Dieckmann, T. Becker, and H. W. Bauer, “Testicular Tumors: Presentation and Role of Diagnostic Delay,” Urol. Int. , vol. 42, no. 4, pp. 241–247, 1987. [33] K. P. Dieckmann, T. Becker, and H. W. Bauer, “Testicular tumors: Presentation and role of diagnostic delay,” Urol. Int. , vol. 42, no. 4, pp. 241–247, 1987. [34] G. J. Post and J. A. Belis, “Delayed presentation of testicular tumors,” South. Med. J. , vol. 73, no. 1, pp. 33–35, 1980. [35] C. Toklu, H. Ozen, A. Sahin, M. Rastadoskouee, and E. Erdem, “Factors involved in diagnostic delay of testicular cancer,” Int. Urol. Nephrol. , vol. 31, no. 3, pp. 383–388, 1999. [36] T. F. Sandeman, “Symptoms and early management of germinal tumours of the testis,” Med. J. Aust. , vol. 2, no. 6, pp. 281–284, 1979. [37] J. A. Thornhill, J. J. Fennelly, D. G. Kelly, A. Walsh, and J. M. Fitzpatrick, “Patients’ Delay in the Presentation of Testis Cancer in Ireland,” Br. J. Urol. , vol. 59, no. 5, pp. 447–451, May 1987. [38] C. E. D. Chilvers, M. Saunders, J. M. Bliss, J. Nicholls, and A. Horwich, “Influence of delay in diagnosis on prognosis in testicular teratoma,” Br. J. Cancer , vol. 59, no. 1, pp. 126–128, 1989. [39] G. R. Prout and P. P. Griffin, “Testicular tumors: Delay in diagnosis and influence on survival,” Am. Fam. Physician , vol. 29, no. 5, pp. 205–209, May 1984. [40] J. M. Davies, “Testicular cancer in England and Wales: some epidemiological aspects,” Lancet , vol. 317, no. 8226, pp. 928–932, Apr. 1981. [41] M. Sun et al. , “Racial disparities and socioeconomic status in men diagnosed with testicular germ cell tumors: A survival analysis,” Cancer , vol. 117, no. 18, pp. 4277–4285, Sep. 2011. [42] L. Collette et al. , “Impact of the treating institution on survival of patients with ‘poor- prognosis’ metastatic nonseminoma,” J. Natl. Cancer Inst. , vol. 91, no. 10, pp. 839–846, May 1999. [43] E. J. Feuer, J. Sheinfeld, and G. J. Bosl, “Does size matter? Association between number of patients treated and patient outcome in metastatic testicular cancer,” Journal of the National Cancer Institute , vol. 91, no. 10. Oxford University Press, pp. 816–818, 19-May-1999. Cite Share Download PDF Status: Under Review Version 1 posted Review # 1 received at journal 22 Mar, 2021 Editorial decision: Major revision 22 Mar, 2021 Review # 2 received at journal 11 Mar, 2021 Reviewer # 2 agreed at journal 25 Feb, 2021 Reviewer # 1 agreed at journal 20 Feb, 2021 Editor assigned by journal 17 Feb, 2021 Reviewers invited by journal 17 Feb, 2021 Submission checks completed at journal 17 Feb, 2021 Editor invited by journal 17 Feb, 2021 First submitted to journal 30 Jan, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-273912","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":13510073,"identity":"f6bf48e1-b4b0-4f93-835a-e872c9fbbcb4","order_by":0,"name":"Zsófia Küronya","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyElEQVRIiWNgGAWjYBACCRiDH0QkFJCiRbIBpMWAFC0GB8AkEVokZ+Q+fFzYZmdvfH514ocHBgzy/GIH8GuRlkg3Np7ZlsxsduPtZgmgwwxnzk7Ar0VOIo1NmreNmc3sxtkNIC0JBreJ01LPYzzj7OYfRGmRhmg5LGHA37uNOFske54xG/OcO24gcYN3m0WCgQRhv0gcT2N8zFNWbc/ff3bzzR8VNvL80gS0gAEjG0gzWKUEfpUI8AeI+Q8Qq3oUjIJRMApGGgAAbZA7Y8u5K2kAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0001-8500-5924","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Zsófia","middleName":"","lastName":"Küronya","suffix":""},{"id":13510074,"identity":"d2a73d7d-6e38-472d-89c4-71c4005b5dda","order_by":1,"name":"Georgina Fröhlich","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Georgina","middleName":"","lastName":"Fröhlich","suffix":""},{"id":13510075,"identity":"8c9a2b9b-8688-4d54-b821-7b7067965d20","order_by":2,"name":"Andrea Ladányi","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Ladányi","suffix":""},{"id":13510076,"identity":"b699a165-51de-4ab2-acd1-bd83b9e1438a","order_by":3,"name":"Tamás Martin","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tamás","middleName":"","lastName":"Martin","suffix":""},{"id":13510077,"identity":"7caf7f60-23f5-48a9-84b8-d4c442fc108d","order_by":4,"name":"Lajos Géczi","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lajos","middleName":"","lastName":"Géczi","suffix":""},{"id":13510078,"identity":"dd7dc5bc-16a9-4a9e-b65a-ad634c17882e","order_by":5,"name":"Fruzsina Gyergyai","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fruzsina","middleName":"","lastName":"Gyergyai","suffix":""},{"id":13510079,"identity":"32827a89-b5d5-4edf-ac70-71b70a28de7a","order_by":6,"name":"Orsolya Horváth","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Orsolya","middleName":"","lastName":"Horváth","suffix":""},{"id":13510080,"identity":"a1c12b47-f97f-4db9-8180-695636421f70","order_by":7,"name":"Gergő Kiszner","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gergő","middleName":"","lastName":"Kiszner","suffix":""},{"id":13510081,"identity":"e8308743-9fc1-4c88-9fc5-1e37ce81eee8","order_by":8,"name":"Ágnes Kovács","email":"","orcid":"","institution":"Boehringer Ingelheim RCV GmbH \u0026 Co KG: Boehringer Ingelheim RCV GmbH und Co KG","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ágnes","middleName":"","lastName":"Kovács","suffix":""},{"id":13510082,"identity":"0ad1f8fe-a146-4b71-a2d0-c2bdcaec5163","order_by":9,"name":"Tamás Dienes","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tamás","middleName":"","lastName":"Dienes","suffix":""},{"id":13510083,"identity":"8a8970f1-c389-4efc-80e9-af44e37a32ed","order_by":10,"name":"Enikő Lénárt","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Enikő","middleName":"","lastName":"Lénárt","suffix":""},{"id":13510084,"identity":"9070c522-c931-4437-a282-c9f60a57cd42","order_by":11,"name":"Krisztián Nagyiványi","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Krisztián","middleName":"","lastName":"Nagyiványi","suffix":""},{"id":13510085,"identity":"040be46c-e5de-4032-8779-5045199bc297","order_by":12,"name":"Tibor Szarvas","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tibor","middleName":"","lastName":"Szarvas","suffix":""},{"id":13510086,"identity":"c88790ac-ff99-45a1-b140-f29419219e62","order_by":13,"name":"Mihály Szőnyi","email":"","orcid":"","institution":"Semmelweis University: Semmelweis Egyetem","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mihály","middleName":"","lastName":"Szőnyi","suffix":""},{"id":13510087,"identity":"21b496da-29f0-4d65-8b43-59a15281a7ae","order_by":14,"name":"Attila Tóth","email":"","orcid":"","institution":"Adherencia","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Attila","middleName":"","lastName":"Tóth","suffix":""},{"id":13510088,"identity":"3ef0c918-df21-4df2-96d6-afb6926e070f","order_by":15,"name":"Krisztina Biró","email":"","orcid":"","institution":"National Institute of Oncology: Orszagos Onkologiai Intezet","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Krisztina","middleName":"","lastName":"Biró","suffix":""}],"badges":[],"createdAt":"2021-02-24 11:16:36","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-273912/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-273912/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":6415964,"identity":"eac7f133-efc8-4705-9058-c1139c28a8d4","added_by":"auto","created_at":"2021-02-26 22:25:44","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":13062,"visible":true,"origin":"","legend":"Illustration of the ladder used in the “MacArthur” Scale of Subjective Social Status (used with the author’s written permission)","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-273912/v1/1580b5a1590051d5988dfbf8.jpeg"},{"id":6416139,"identity":"737434ad-8bf0-4097-9bbc-8cc3ff330f09","added_by":"auto","created_at":"2021-02-26 22:28:44","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":337010,"visible":true,"origin":"","legend":"Kaplan-Meier curves for all patients vs. seminoma vs. non-seminoma patients (a), patients separated according to social quartile: all patients, (b) non-seminoma (c), seminoma, (d) patient delay: non-seminoma(e), seminoma(f) \n\nSocial status value: At the top of the ladder are the people who are the best off, those who have the most money, the most education, and the best jobs. At the bottom are the people who are the worst off, those who have the least money, least education, worst jobs, or no job. \nCommunity status value: Think of this ladder as representing where people stand in their communities. People define community in different ways; please define it in whatever way is most meaningful to you. At the top of the ladder are people who have the highest standing in their community. At the bottom are the people who have the lowest standing in their community.\n\n“Please place an ‘X’ on the rung that best represents where you think you stand on the ladder.”\n","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-273912/v1/58f2c82320ff2d121a743e95.png"},{"id":13672527,"identity":"60a9937a-8ce2-4680-bdaf-89ff05b71326","added_by":"auto","created_at":"2021-09-17 11:13:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":542706,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-273912/v1/3876844d-d3b9-4b30-8a82-5ca5a1b4b722.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eLow Socioeconomic Status is a Risk Factor for Delay to Treatment and Mortality of Testicular Cancer Patients in Hungary. A Prospective Study\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eMalignant testicular germ cell cancer (TGCC) is relatively uncommon, however, this is still the leading type of cancer in men between the ages of 20 and 40 years. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Due to huge improvements in imaging and chemotherapy, mortality rates in patients with testicular cancer have declined in recent decades. In the most affluent world regions, while rapid increases in incidence rates have been observed lately, the mortality rates declined to 0.2\u0026ndash;0.3 per 100,000. However, in Central and Eastern European (CEE) countries (i.e., Bulgaria, Czech Republic, Hungary, Poland, Romania, and Slovakia), rates have only moderately declined and were still 1.3/100,000[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e][\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] for men aged between 20 and 44 years in 1995\u0026ndash;1997. In the first decade of the 2000s, a significant decline in testicular cancer patients\u0026rsquo; mortality rates appeared also in CEE countries, but the ratio is still higher than in the more developed EU members. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] According to a WHO database, Hungary and Latvia had the worst TGCC mortality rate in Europe (0.9/100,000) between 2000 and 2006.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The slower and delayed declines in the less developed, lower resource countries imply that the high cost of appropriate treatments together with inadequate patient referral systems are responsible for the high mortality rates and less favorable trends. Another factor of the slower progress may partly relate to differences in socioeconomic status (SES), i.e. men with lower SES may be characterized by a lack of awareness and maybe less likely to seek immediate medical help, moreover, they tend to have the worst access to medical service, particularly in rural and remote communities. There is extensive literature describing SES differences and cancer survival in countries around the world in various health care systems. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e][\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e][\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e][\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThe authors of this report prospectively evaluated the effects of subjective social status (SSS) on delay to diagnosis, stage distribution, and cancer-specific mortality (CSM) in men with TGCC. The studied patient cohort was treated at the National Institute of Oncology GU department, which is the main germ cell cancer center in Hungary, treating roughly 60% of the approximately 600 Hungarian TGCC patients yearly.\u003c/p\u003e\u003cp\u003eThe aim of this research was to investigate how the patients\u0026rsquo; socioeconomic status affects the time elapsed between onset of symptoms and diagnosis, and therapy outcome.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e2.1. Ethical statement\u003c/p\u003e\u003cp\u003eThis prospective, non-interventional study was carried out between January 2016 and January 2018, at the National Institute of Oncology. The database lock occurred in September 2019. The study was performed in accordance with Hungarian laws and regulations and was approved by the Hungarian National Scientific Ethical Committee (approval number: 44476-2/2016), and as per the standards of the World Medical Association Declaration of Helsinki. All patients who were willing to participate signed informed consent.\u003c/p\u003e\u003cp\u003e2.2. Study population\u003c/p\u003e\u003cp\u003eInclusion criteria included male patients over 16 years old (inclusive), with newly diagnosed testicular cancer with a gonadal onset.\u003c/p\u003e\u003cp\u003eClinical stage and prognosis were determined according to the Union for International Cancer Control (UICC), [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the International Germ Cell Cancer Collaborative Group (IGCCCG) [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] based on the pathology report, the tumor marker (AFP, HCG, LDH) level, and the CT scan. Castration was the first-line treatment for the majority of patients (Table\u0026nbsp;1), followed by surveillance or adjuvant chemotherapy (St I), or by multiple cycles of platinum-based chemotherapy, and salvage surgery where needed (St II-III). In 16 patients whose conditions related to metastatic dissemination required immediate chemotherapy, orchiectomy was postponed until the completion of chemotherapy. Patients received the internationally recognized standard of care, based on the current European Society for Medical Oncology (ESMO) guideline.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e2.3 Assessment of the objective and subjective socioeconomic status\u003c/p\u003e\u003cp\u003eThe subjective social status (SSS) and objective socioeconomic status (SES) questionnaires were completed on the first consultation visit of newly diagnosed TGCC patients. The SSS was determined based on the MacArthur Scale of Subjective Status questionnaire. After the owner\u0026rsquo;s written permission for usage and linguistic validation, the questionnaire has been translated into Hungarian and was adapted for this study. MacArthur scale is a social or community hierarchy ladder used by the patients based on their deemed place; with values of 1\u0026ndash;10. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e][\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e][\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e][\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] We measured two variables: social status, and community status value (Fig.\u0026nbsp;1). For objective SES patient\u0026rsquo;s highest educational attainment, residency, income, possession of consumer durable goods, occupational class, and the parents\u0026rsquo; highest educational level were evaluated. An index number was created based on the educational level, the number of consumer durable goods, and the size of living area per capita. Based on this index number, patients were divided into 4 quartiles. The first quartile was the lowest, with the poorest status and lowest educational level. The section on illness comprised of questions including the time gap between the first symptoms and visiting a doctor (patient delay, PD), and between the first doctor\u0026rsquo;s visit and first consultation at our institute (doctor\u0026rsquo;s delay, DD). Histology, stage, and treatment outcome were extracted from the patient database.\u003c/p\u003e\u003cp\u003e2.4. Statistical analyses\u003c/p\u003e\u003cp\u003eStatistical analyses were performed using SPSS 22.0 (IBM Corp.) and Statistica 12.5 (StatSoft, Tulsa, OK, USA). To detect the association between the doctor\u0026rsquo;s delay and overall survival (OS) Mann-Whitney U test was used while the correlation between the patient\u0026rsquo;s delay and survival was determined by logistic regression. To examine the effect of SES on survival Fisher exact test was carried out. The association between various patient characteristics and OS were analyzed by Kaplan-Meier analysis. To examine the correlation between patient education and PD, and between SSS and SES, Spearman rank correlation was performed. Results were considered significant at p values lower than 0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e3.1. Patient characteristics\u003c/p\u003e\n\u003cp\u003eAltogether, 306 patients filled out the questionnaire. Analyses were performed on 303 patients who met the inclusion criteria (3 cases with non-gonadal origin were excluded from the analysis). The patients\u0026rsquo; mean age was 35.9 years (seminoma 38.5, non-seminoma 33.1) (Table\u0026nbsp;2). The mother\u0026rsquo;s mean age at childbirth was 26 years whilst the father\u0026rsquo;s mean age at childbirth was 29.1 years. Patients belonged to a relatively high socioeconomic class, 103 (34%) patients had a university or college degree, which is twice as many as the Hungarian society average. [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e] SSS among patients was 5.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70 while the Hungarian average among males in this age group is 3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03 (out of 10). [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e]. Fourteen patients died during the study period, they were significantly older than the surviving patients, 41.6 vs. 35.9 years (p\u0026thinsp;=\u0026thinsp;0.0277) (Table\u0026nbsp;1). Among patients with metastatic seminoma 152 (98.7%) belonged to the good and 2 (1.3%) to the intermediate prognostic group, while among those with non-seminoma 116 (77.9%), 12 (8.0%), and 21 (14.1%) belonged to good, intermediate and poor prognostic group, respectively. Table\u0026nbsp;3 shows the stage distribution among seminoma and non-seminoma patients. The majority of patients belonged to stage I (seminoma: 71.5% and non-seminoma 47.6%), though a higher proportion of non-seminoma patients had metastatic disease (StII/StIII) at diagnosis (28.5% seminoma vs. 52.4% non-seminoma).\u003c/p\u003e\n\u003cp\u003e3.2. Objective and subjective social status\u003c/p\u003e\n\u003cp\u003eRegarding patients\u0026rsquo; residence type, distance from the National Institute of Oncology, number of household members, number of members with income, and internet usage frequency there was no difference between the seminoma and non-seminoma group (Table\u0026nbsp;2). Table\u0026nbsp;4 presents social quartiles based on objective social status and the distribution of SSS. The distribution of SSS was normal (Table\u0026nbsp;4). The full range of score distribution (1\u0026ndash;10) was observed. The mean SSS value for the entire sample was 5.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70, while the median and mode coincided between the fifth and sixth rung. In terms of SSS, there was also no difference between seminoma and non-seminoma patients (p\u0026thinsp;=\u0026thinsp;0.7898).\u003c/p\u003e\n\u003cp\u003e3.3. Patients\u0026rsquo; objective versus subjective self-grade values\u003c/p\u003e\n\u003cp\u003eThe patient\u0026rsquo;s SSS was compared to the SES indicators. Both the social ladder value and the community ladder value exhibited a significant correlation with the objective socioeconomic status-based quartiles (r\u0026thinsp;=\u0026thinsp;0.508 and r\u0026thinsp;=\u0026thinsp;0.417, respectively, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\n\u003cp\u003e3.4. Factors associated with patient\u0026rsquo;s delay and doctor\u0026rsquo;s delay\u003c/p\u003e\n\u003cp\u003eThe diagnostic time path was from within 1 week to over 1 year, with the \u0026lsquo;1 week-1 month\u0026rsquo; being the median (102 patients). We found a negative correlation between the father\u0026rsquo;s education and patient delay (PD) (r=-0.12, p\u0026thinsp;=\u0026thinsp;0.0383), and an even stronger negative correlation between the mother\u0026rsquo;s education and the PD, as well as the patient\u0026rsquo;s education and the PD (r=-0.21, p\u0026thinsp;=\u0026thinsp;0.0003, and r=-0.20, p\u0026thinsp;=\u0026thinsp;0.0005, respectively). Table\u0026nbsp;5 shows PD based on the educational level of the patients. Both PD and DD negatively correlated with social quartile (r=-0.18, p\u0026thinsp;=\u0026thinsp;0.0022 and r=-0.15, p\u0026thinsp;=\u0026thinsp;0.0131, respectively). The social quartile value showed a stronger association with PD than with DD, the latter also correlated with the distance (km) from the National Institute of Oncology (r\u0026thinsp;=\u0026thinsp;0.12, p\u0026thinsp;=\u0026thinsp;0.0347). Each PD and DD were significantly longer for deceased patients than for surviving patients (Table\u0026nbsp;6).\u003c/p\u003e\n\u003cp\u003e3.5. Patient delay, social quartile, and overall survival\u003c/p\u003e\n\u003cp\u003eOf the 14 patients who died during the study course, 11 (78.6%) were in the social quartile 1 (lowest), compared to 73 of the 289 surviving patients (25.3%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;5) Fig.\u0026nbsp;2 shows the OS based on the social quartile, and PD for all patients and separated for non-seminoma and seminoma patients. 57.2% of deceased patients waited more than a year before seeking help, while this number for the surviving patients was 8.0% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Longer PD was associated with a more advanced stage in non-seminoma, but not in seminoma patients, the correlation coefficient for NS was 0.321 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) hence PD significantly influenced OS in NS (p\u0026thinsp;=\u0026thinsp;0.0021) but not in S (p\u0026thinsp;=\u0026thinsp;0.13) (Fig.\u0026nbsp;2). Since PD was correlated with social quartile, as mentioned above, and resulted in a more advanced stage in non-seminoma, lower social quartile resulted in higher mortality in NS patients (p\u0026thinsp;=\u0026thinsp;0.0048) but not in S patients (p\u0026thinsp;=\u0026thinsp;0.36) where PD was not associated with more advanced stage.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study has been conducted at one site (National Institute of Oncology, Department of Genitourinary Medical Oncology and Clinical Pharmacology), between 2016 and 2018, and includes the prospective data analysis of the socioeconomic status of patients followed or treated with testicular cancer. The 303 patients who participated in the study, is approximately half of the yearly Hungarian TGCC incidence (600\u0026ndash;650 cases/year). [\u003cspan class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eInequalities in cancer mortality and morbidity between populations with different (lower and higher) socioeconomic positions are widely described in the literature [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. We measured both the subjective (social ladder, SSS) and objective (SES) social status and found that both the social ladder value and the community ladder value exhibited a significant correlation with the objective socioeconomic status-based quartiles. The association between SES and SSS, which is distinctive in different cultural groups, was reported in several papers.[\u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e] SSS is easier to use because many people do not want to report their income and education levels. Furthermore, it seems to predict health and general well-being better than objective SES measurements. [\u003cspan class=\"CitationRef\"\u003e17\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eIn the current study, we found a major deviation in terms of the patient\u0026rsquo;s highest education level compared to the country averages Those educated to college/university level (34%) were represented 1.5 times more as the Hungarian society averages suggest, while those with the lowest education (8%) have been presented in a significantly lower extent compared to the Hungarian average (27%). [\u003cspan class=\"CitationRef\"\u003e18\u003c/span\u003e] SSS among patients was 5.57\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70 while the Hungarian average among males in this age group is 3.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.03 (out of 10). [\u003cspan class=\"CitationRef\"\u003e19\u003c/span\u003e] Numerous reports indicate that TGCC has for some time tended to occur disproportionately among men of high socioeconomic status and the sons of women of high socioeconomic status [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e], while other reports have not found such associations [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eSince both the intensity of treatment and prognosis are based on the extent of disease at presentation, a testicular cancer diagnosis must not be delayed. Among our TGCC patients, PD and DD showed significant relations with social status. In terms of PD, the most influential was the mother\u0026rsquo;s and patient\u0026rsquo;s education. Delay in the diagnosis of testicular cancer is well documented [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e]. Dieckmann and colleagues found that PD was related to educational level. College-educated men were found to have shorter mean and median delay [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e]. The less educated patients may actually believe that a larger testicle makes a more virile man. [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. On the other hand, Toklu et al. have not found a correlation between the annual income, the educational level, and the delay to treatment [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e]. Physician-mediated delay most commonly results from the misdiagnosis of a testis tumor as an infection. In one study of 335 testicular cancer patients, one third were treated initially with antibiotics for presumed epididymitis[\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. In our cohort social quartile value showed a stronger association with PD than with DD, the latter also correlated with the distance (km) from the National Institute of Oncology.\u003c/p\u003e\n\u003cp\u003eThere is only a limited reference in the literature to the possible association between the patient\u0026rsquo;s SES and the stage of their disease. Seminomas can have an indolent growth, and delay in diagnosis usually does not result in a more advanced stage. [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] Since in our study PD in seminoma patients did not influence the stage, thus the social quartile in seminoma did not determine the survival significantly. For non-seminoma patients, there is a clearer association between delay in diagnosis and advanced disease. [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e] [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] and the increased delay has also been associated with decreased survival [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e]. PD among our non-seminoma patients presented a more advanced stage, and based on our research, PD was significantly correlated with social status, therefore social quartile and survival also had significant interdependence in non-seminoma patients. In the study of Davies, TGCC patients with lower SES had higher mortality rates. [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. Sun et al. reported from their multivariate analysis that low SES groups had significantly higher cancer-related mortality rates, as well as higher collective mortality rates retrospectively.[\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e] This was in line with the findings of Davies et al. who reported a higher mortality rate among those educated at the vocational school level.[\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] This has also been proved by the results reported in this research, as 10 out of 14 deceased patients were educated to that level, and 9 out of 10 belonged to the lowest quartile. The number of deceased patients was significantly higher among those who waited at least 1 year before the first doctor visit. According to our knowledge, there is no similar finding, published in our research area.\u003c/p\u003e\n\u003cp\u003eThe mortality rate among our patients (4.6%) was better compared to the Hungarian average (7.6%), and this underscores the importance of having the TGCC patients managed in a specialized center, It has been reported earlier that specialist centers demonstrate superior results to nonspecialist centers [\u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e][\u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eLimitation of the study\u003c/p\u003e\n\u003cp\u003eSimilar to other studies measuring patient-reported timelines, bias may occur when patients recall the exact delay period.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eTo our knowledge, this is the first study that prospectively evaluated the TGCC patients\u0026rsquo; objective and subjective social statuses along with survival ratios, all other studies investigated them retrospectively, and indirectly. Mother\u0026rsquo;s and patient education posed an influent aspect of PD; higher education led to a shorter PD period and hence better survival in non-seminoma patients.\u003c/p\u003e\n\u003cp\u003eBased on our result, we conclude that to improve survival, we should promote testicular cancer awareness, especially among the most deprived populations, and their health care providers.\u003c/p\u003e\n"},{"header":"Abbreviations","content":"\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Taba\" border=\"1\"\u003e\n\u003cthead\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eAFP\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eAlpha-fetoprotein\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCEE\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eCentral and Eastern European countries\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCT\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eComputed tomography\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eCSM\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eCancer-specific mortality\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eDD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eDoctor\u0026rsquo;s delay\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEU\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eEuropean Union\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eGU\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eGenito-urinary\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eHCG\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eHuman chorionic gonadotropin\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eIGCCCG\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eInternational Germ Cell Cancer Collaborative Group\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eKm\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eKilometer\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eLDH\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eLactate dehydrogenase\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eOS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eOverall survival\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePD\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003ePatient delay\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSES\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eSocioeconomic status\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSSS\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eSubjective social status\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eSt\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eStage\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eTGCC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eTesticular germ cell cancer\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eUICC\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eUnion for International Cancer Control\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px;\" align=\"left\"\u003e\n\u003cp\u003eWorld health organization\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAuthor information:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAffiliations:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNational Institute of Oncology, Budapest, Hungary\u003c/p\u003e\n\u003cp\u003eZs\u0026oacute;fia K\u0026uuml;ronya, Georgina Fr\u0026ouml;hlich, Andrea Lad\u0026aacute;nyi, Tam\u0026aacute;s Martin, Lajos G\u0026eacute;czi, Fruzsina Gyergyai, Orsolya Horv\u0026aacute;th, Gergő Kiszner, Tam\u0026aacute;s Dienes, Enikő L\u0026eacute;n\u0026aacute;rt, Kriszti\u0026aacute;n Nagyiv\u0026aacute;nyi Krisztina Bir\u0026oacute;\u003c/p\u003e\n\u003cp\u003eE\u0026ouml;tv\u0026ouml;s Lor\u0026aacute;nd University, Faculty of Science, Budapest, Hungary\u003c/p\u003e\n\u003cp\u003eGeorgina Fr\u0026ouml;hlich,\u003c/p\u003e\n\u003cp\u003eBoehringer Ingelheim RCV GmbH \u0026amp; Co. KG Branch Office Budapest, Hungary\u003c/p\u003e\n\u003cp\u003e\u0026Aacute;gnes Kov\u0026aacute;cs\u003c/p\u003e\n\u003cp\u003eSemmelweis University Budapest, Hungary\u003c/p\u003e\n\u003cp\u003eTibor Szarvas, Mih\u0026aacute;ly Szőnyi\u003c/p\u003e\n\u003cp\u003eAdherencia.net Kft., Budapest, Hungary\u003c/p\u003e\n\u003cp\u003eAttila T\u0026oacute;th\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZs\u0026oacute;fia K\u0026uuml;ronya, \u003ca href=\"mailto:[email protected]\"\[email protected]\u003c/a\u003e\u003c/p\u003e\n\u003cp\u003eNational Institute of Oncology, Department of Genitourinary Medical Oncology and Clinical Pharmacology, R\u0026aacute;th Gy\u0026ouml;rgy u. 7-9., Budapest, H-1122, Hungary\u003c/p\u003e\n\u003ch3\u003eContributions:\u003c/h3\u003e\n\u003cp\u003eZs.K, and K.B planned and conducted the research with the help of T.M. Statistical analysis was carried out by G.F and \u0026Aacute;.K. The SSS and SES questionnaires were created by A.T. Critical revision was carried out by A.L. All the remaining authors (L.G, F.Gy, O.H, G.K, T. D, E.L, K N.) helped with data collection. All authors have read and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe was approved by the Hungarian National Scientific Ethical Committee (approval number: 44476-2/2016),. All patients who were willing to participate signed informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eWe declare that we have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e[1] F. Bray, J. Ferlay, I. Soerjomataram, R. L. Siegel, L. A. Torre, and A. Jemal, \u0026ldquo;Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries,\u0026rdquo; \u003cem\u003eCA. Cancer J. Clin.\u003c/em\u003e, vol. 68, no. 6, pp. 394\u0026ndash;424, Nov. 2018.\u003c/p\u003e\n\u003cp\u003e[2] F. Bray, L. Richiardi, A. Ekbom, E. Pukkala, M. Cuninkova, and H. M\u0026oslash;ller, \u0026ldquo;Trends in testicular cancer incidence and mortality in 22 European countries: Continuing increases in incidence and declines in mortality,\u0026rdquo; \u003cem\u003eInt. J. Cancer\u003c/em\u003e, vol. 118, no. 12, pp. 3099\u0026ndash;3111, Jun. 2006.\u003c/p\u003e\n\u003cp\u003e[3] C. Bosetti, P. Bertuccio, L. Chatenoud, E. Negri, C. La Vecchia, and F. Levi, \u0026ldquo;Trends in mortality from urologic cancers in Europe, 1970-2008,\u0026rdquo; \u003cem\u003eEur. Urol.\u003c/em\u003e, vol. 60, no. 1, pp. 1\u0026ndash;15, Jul. 2011.\u003c/p\u003e\n\u003cp\u003e[4] F. Levi, C. La Vecchia, P. Boyle, F. Lucchini, and E. Negri, \u0026ldquo;Western and eastern European trends in testicular cancer mortality.,\u0026rdquo; \u003cem\u003eLancet (London, England)\u003c/em\u003e, vol. 357, no. 9271, pp. 1853\u0026ndash;4, Jun. 2001.\u003c/p\u003e\n\u003cp\u003e[5] A. Znaor and F. Bray, \u0026ldquo;Thirty year trends in testicular cancer mortality in Europe: Gaps persist between the East and West,\u0026rdquo; \u003cem\u003eActa Oncol. (Madr).\u003c/em\u003e, vol. 51, no. 7, pp. 956\u0026ndash;958, Sep. 2012.\u003c/p\u003e\n\u003cp\u003e[6] \u0026ldquo;WHO Mortality Database - WHO.\u0026rdquo; [Online]. Available: https://www.who.int/data/data-collection-tools/who-mortality-database. [Accessed: 16-Oct-2020].\u003c/p\u003e\n\u003cp\u003e[7] A. Rosengren and L. Wilhelmsen, \u0026ldquo;Cancer incidence, mortality from cancer and survival in men of different occupational classes,\u0026rdquo; \u003cem\u003eEur. J. Epidemiol.\u003c/em\u003e, vol. 19, no. 6, pp. 533\u0026ndash;540, Jun. 2004.\u003c/p\u003e\n\u003cp\u003e[8] G. K. Singh, S. D. Williams, M. Siahpush, and A. Mulhollen, \u0026ldquo;Socioeconomic, rural-urban, and racial inequalities in US cancer mortality: Part I-All cancers and lung cancer and part II-Colorectal, prostate, breast, and cervical cancers,\u0026rdquo; \u003cem\u003eJ. Cancer Epidemiol.\u003c/em\u003e, vol. 2011, 2011.\u003c/p\u003e\n\u003cp\u003e[9] D. Vagero and G. Persson, \u0026ldquo;Cancer survival and social class in Sweden,\u0026rdquo; \u003cem\u003eJ. Epidemiol. Community Health\u003c/em\u003e, vol. 41, no. 3, pp. 204\u0026ndash;209, 1987.\u003c/p\u003e\n\u003cp\u003e[10] G. D. Smith, D. Leon, M. J. Shipley, and G. Rose, \u0026ldquo;Socioeconomic differentials in cancer among men,\u0026rdquo; \u003cem\u003eInt. J. Epidemiol.\u003c/em\u003e, vol. 20, no. 2, pp. 339\u0026ndash;345, Jun. 1991.\u003c/p\u003e\n\u003cp\u003e[11] G. M. W. C. Brierley J, Ed., \u003cem\u003eTNM classification of malignant tumours, Eighth edition\u003c/em\u003e. John Wiley \u0026amp; Sons, Inc, Chichester, West Sussex, UK ; Hoboken, NJ, 2016.\u003c/p\u003e\n\u003cp\u003e[12] G. M. Mead and S. P. Stenning, \u0026ldquo;The International Germ Cell Consensus Classification: A new prognostic factor-based staging classification for metastatic germ cell tumours,\u0026rdquo; \u003cem\u003eClinical Oncology\u003c/em\u003e, vol. 9, no. 4. Elsevier Ltd, pp. 207\u0026ndash;209, 1997.\u003c/p\u003e\n\u003cp\u003e[13] J. Oldenburg \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Testicular seminoma and non-seminoma: ESMO clinical practice guidelines for diagnosis, treatment and follow-up,\u0026rdquo; \u003cem\u003eAnn. Oncol.\u003c/em\u003e, vol. 24, no. SUPPL.6, 2013.\u003c/p\u003e\n\u003cp\u003e[14] N. E. Adler, E. S. Epel, G. Castellazzo, and J. R. Ickovics, \u0026ldquo;Relationship of subjective and objective social status with psychological and physiological functioning: Preliminary data in healthy, White women.,\u0026rdquo; \u003cem\u003eHeal. Psychol.\u003c/em\u003e, vol. 19, no. 6, pp. 586\u0026ndash;592, 2000.\u003c/p\u003e\n\u003cp\u003e[15] J. M. Ostrove, N. E. Adler, M. Kuppermann, and A. E. Washington, \u0026ldquo;Objective and subjective assessments of socioeconomic status and their relationship to self-rated health in an ethnically diverse sample of pregnant women.,\u0026rdquo; \u003cem\u003eHeal. Psychol.\u003c/em\u003e, vol. 19, no. 6, pp. 613\u0026ndash;618, 2000.\u003c/p\u003e\n\u003cp\u003e[16] E. Goodman, N. E. Adler, I. Kawachi, A. L. Frazier, B. Huang, and G. A. Colditz, \u0026ldquo;Adolescents\u0026rsquo; perceptions of social status: development and evaluation of a new indicator.,\u0026rdquo; \u003cem\u003ePediatrics\u003c/em\u003e, vol. 108, no. 2, 2001.\u003c/p\u003e\n\u003cp\u003e[17] A. Singh-Manoux, N. E. Adler, and M. G. Marmot, \u0026ldquo;Subjective social status: Its determinants and its association with measures of ill-health in the Whitehall II study,\u0026rdquo; \u003cem\u003eSoc. Sci. Med.\u003c/em\u003e, vol. 56, no. 6, pp. 1321\u0026ndash;1333, Mar. 2003.\u003c/p\u003e\n\u003cp\u003e[18] Bojer A, Erdei V, V\u0026ouml;r\u0026ouml;s C, \u0026ldquo;(2017) Mikrocenzus 2016, 4. Iskol\u0026aacute;zotts\u0026aacute;gi adatok.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e[19] M. Kopp, \u0026Aacute;. Skrabski, J. R\u0026eacute;thelyi, I. Kawachi, and N. E. Adler, \u0026ldquo;Self-rated health, subjective social status, and middle-aged mortality in a changing society,\u0026rdquo; \u003cem\u003eBehav. Med.\u003c/em\u003e, vol. 30, no. 2, pp. 65\u0026ndash;72, 2004.\u003c/p\u003e\n\u003cp\u003e[20] \u0026ldquo;Hungarian National Cancer Registry.\u0026rdquo; [Online]. Available: http://ghdx.healthdata.org/organizations/national-cancer-registry-hungary-10.\u003c/p\u003e\n\u003cp\u003e[21] \u0026ldquo;Area Socioeconomic Variations in U.S. Cancer 1975 - 1999 - SEER Publications.\u0026rdquo; [Online]. Available: https://seer.cancer.gov/archive/publications/ses/. [Accessed: 17-Oct-2020].\u003c/p\u003e\n\u003cp\u003e[22] K. B. Curhan \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Subjective and Objective Hierarchies and Their Relations to Psychological Well-Being: A U.S./Japan Comparison,\u0026rdquo; \u003cem\u003eSoc. Psychol. Personal. Sci.\u003c/em\u003e, vol. 5, no. 8, pp. 855\u0026ndash;864, Nov. 2014.\u003c/p\u003e\n\u003cp\u003e[23] N. Adler, A. Singh-Manoux, J. Schwartz, J. Stewart, K. Matthews, and M. G. Marmot, \u0026ldquo;Social status and health: A comparison of British civil servants in Whitehall-II with European- and African-Americans in CARDIA,\u0026rdquo; \u003cem\u003eSoc. Sci. Med.\u003c/em\u003e, vol. 66, no. 5, pp. 1034\u0026ndash;1045, Mar. 2008.\u003c/p\u003e\n\u003cp\u003e[24] N. Goldman, J. C. Cornman, and M. C. Chang, \u0026ldquo;Measuring subjective social status: A case study of older Taiwanese,\u0026rdquo; \u003cem\u003eJ. Cross. Cult. Gerontol.\u003c/em\u003e, vol. 21, no. 1\u0026ndash;2, pp. 71\u0026ndash;89, Mar. 2006.\u003c/p\u003e\n\u003cp\u003e[25] J. R. Garza, B. A. Glenn, R. S. Mistry, N. A. Ponce, and F. J. Zimmerman, \u0026ldquo;Subjective Social Status and Self-Reported Health Among US-born and Immigrant Latinos,\u0026rdquo; \u003cem\u003eJ. Immigr. Minor. Heal.\u003c/em\u003e, vol. 19, no. 1, pp. 108\u0026ndash;119, Feb. 2017.\u003c/p\u003e\n\u003cp\u003e[26] D. Schottenfeld, M. E. Warshauer, S. Sherlock, A. G. Zauber, M. Leder, and R. Payne, \u0026ldquo;The epidemiology of testicular cancer in young adults,\u0026rdquo; \u003cem\u003eAm. J. Epidemiol.\u003c/em\u003e, vol. 112, no. 2, pp. 232\u0026ndash;246, 1980.\u003c/p\u003e\n\u003cp\u003e[27] A. J. Swerdlow, A. J. Douglas, S. R. A. Huttly, and P. G. Smith, \u0026ldquo;Cancer of the testis, socioeconomic status, and occupation,\u0026rdquo; \u003cem\u003eBr. J. Ind. Med.\u003c/em\u003e, vol. 48, no. 10, pp. 670\u0026ndash;674, 1991.\u003c/p\u003e\n\u003cp\u003e[28] A. Prener, C. cheng Hsieh, G. Engholm, D. Trichopoulos, and O. M. Jensen, \u0026ldquo;Birth order and risk of testicular cancer,\u0026rdquo; \u003cem\u003eCancer Causes Control\u003c/em\u003e, vol. 3, no. 3, pp. 265\u0026ndash;272, May 1992.\u003c/p\u003e\n\u003cp\u003e[29] J. W. Moul, \u0026ldquo;Timely Diagnosis of Testicular Cancer,\u0026rdquo; \u003cem\u003eUrologic Clinics of North America\u003c/em\u003e, vol. 34, no. 2. Urol Clin North Am, pp. 109\u0026ndash;117, May-2007.\u003c/p\u003e\n\u003cp\u003e[30] J. W. Moul, D. F. Paulson, R. K. Dodge, and P. J. Walther, \u0026ldquo;Delay in diagnosis and survival in testicular cancer: Impact of effective therapy and changes during 18 years,\u0026rdquo; \u003cem\u003eJ. Urol.\u003c/em\u003e, vol. 143, no. 3, pp. 520\u0026ndash;523, 1990.\u003c/p\u003e\n\u003cp\u003e[31] G. J. Bosl \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Impact of delay in diagnosis on clinical stage of testicular cancer,\u0026rdquo; \u003cem\u003eLancet\u003c/em\u003e, vol. 318, no. 8253, pp. 970\u0026ndash;973, Oct. 1981.\u003c/p\u003e\n\u003cp\u003e[32] K.-P. Dieckmann, T. Becker, and H. W. Bauer, \u0026ldquo;Testicular Tumors: Presentation and Role of Diagnostic Delay,\u0026rdquo; \u003cem\u003eUrol. Int.\u003c/em\u003e, vol. 42, no. 4, pp. 241\u0026ndash;247, 1987.\u003c/p\u003e\n\u003cp\u003e[33] K. P. Dieckmann, T. Becker, and H. W. Bauer, \u0026ldquo;Testicular tumors: Presentation and role of diagnostic delay,\u0026rdquo; \u003cem\u003eUrol. Int.\u003c/em\u003e, vol. 42, no. 4, pp. 241\u0026ndash;247, 1987.\u003c/p\u003e\n\u003cp\u003e[34] G. J. Post and J. A. Belis, \u0026ldquo;Delayed presentation of testicular tumors,\u0026rdquo; \u003cem\u003eSouth. Med. J.\u003c/em\u003e, vol. 73, no. 1, pp. 33\u0026ndash;35, 1980.\u003c/p\u003e\n\u003cp\u003e[35] C. Toklu, H. Ozen, A. Sahin, M. Rastadoskouee, and E. Erdem, \u0026ldquo;Factors involved in diagnostic delay of testicular cancer,\u0026rdquo; \u003cem\u003eInt. Urol. Nephrol.\u003c/em\u003e, vol. 31, no. 3, pp. 383\u0026ndash;388, 1999.\u003c/p\u003e\n\u003cp\u003e[36] T. F. Sandeman, \u0026ldquo;Symptoms and early management of germinal tumours of the testis,\u0026rdquo; \u003cem\u003eMed. J. Aust.\u003c/em\u003e, vol. 2, no. 6, pp. 281\u0026ndash;284, 1979.\u003c/p\u003e\n\u003cp\u003e[37] J. A. Thornhill, J. J. Fennelly, D. G. Kelly, A. Walsh, and J. M. Fitzpatrick, \u0026ldquo;Patients\u0026rsquo; Delay in the Presentation of Testis Cancer in Ireland,\u0026rdquo; \u003cem\u003eBr. J. Urol.\u003c/em\u003e, vol. 59, no. 5, pp. 447\u0026ndash;451, May 1987.\u003c/p\u003e\n\u003cp\u003e[38] C. E. D. Chilvers, M. Saunders, J. M. Bliss, J. Nicholls, and A. Horwich, \u0026ldquo;Influence of delay in diagnosis on prognosis in testicular teratoma,\u0026rdquo; \u003cem\u003eBr. J. Cancer\u003c/em\u003e, vol. 59, no. 1, pp. 126\u0026ndash;128, 1989.\u003c/p\u003e\n\u003cp\u003e[39] G. R. Prout and P. P. Griffin, \u0026ldquo;Testicular tumors: Delay in diagnosis and influence on survival,\u0026rdquo; \u003cem\u003eAm. Fam. Physician\u003c/em\u003e, vol. 29, no. 5, pp. 205\u0026ndash;209, May 1984.\u003c/p\u003e\n\u003cp\u003e[40] J. M. Davies, \u0026ldquo;Testicular cancer in England and Wales: some epidemiological aspects,\u0026rdquo; \u003cem\u003eLancet\u003c/em\u003e, vol. 317, no. 8226, pp. 928\u0026ndash;932, Apr. 1981.\u003c/p\u003e\n\u003cp\u003e[41] M. Sun \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Racial disparities and socioeconomic status in men diagnosed with testicular germ cell tumors: A survival analysis,\u0026rdquo; \u003cem\u003eCancer\u003c/em\u003e, vol. 117, no. 18, pp. 4277\u0026ndash;4285, Sep. 2011.\u003c/p\u003e\n\u003cp\u003e[42] L. Collette \u003cem\u003eet al.\u003c/em\u003e, \u0026ldquo;Impact of the treating institution on survival of patients with \u0026lsquo;poor- prognosis\u0026rsquo; metastatic nonseminoma,\u0026rdquo; \u003cem\u003eJ. Natl. Cancer Inst.\u003c/em\u003e, vol. 91, no. 10, pp. 839\u0026ndash;846, May 1999.\u003c/p\u003e\n\u003cp\u003e[43] E. J. Feuer, J. Sheinfeld, and G. J. Bosl, \u0026ldquo;Does size matter? Association between number of patients treated and patient outcome in metastatic testicular cancer,\u0026rdquo; \u003cem\u003eJournal of the National Cancer Institute\u003c/em\u003e, vol. 91, no. 10. Oxford University Press, pp. 816\u0026ndash;818, 19-May-1999.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"testicular cancer, socioeconomic status, patient delay, doctor’s delay","lastPublishedDoi":"10.21203/rs.3.rs-273912/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-273912/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e. In Hungary, the mortality rate for testicular germ cell cancer (TGCC) is 7.6% which is significantly higher than the EU average. We prospectively evaluated the effect of socioeconomic status on patient delay, doctor’s delay, and therapy outcomes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u0026nbsp;Questionnaires on subjective (MacArthur Subjective Status Scale), objective (wealth, education, and housing data) social status, and on patient’s and doctors’ delays were completed by newly diagnosed TGCC patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u0026nbsp;Patients belonged to a relatively high socioeconomic class, a university degree was double the Hungarian average, Cancer-specific mortality in the highest social quartile was 1.56% while in the lowest social quartile 13.09% (p=0.02). In terms of patient delay, 57.2% of deceased patients waited more than a year before seeking help, while this number for the surviving patients was 8.0% (p=0.0000). Longer patient delay was associated with a more advanced stage in non-seminoma but not in seminoma, the correlation coefficient for non-seminoma was 0.321 (p\u0026lt;0.001). For patient delay, the most important variables were the mother’s and patient’s education levels (r=-0.21, p=0.0003, and r=-0.20, p=0.0005), respectively. Since the patient delay was correlated with the social quartile and resulted in a more advanced stage in non-seminoma, the lower social quartile resulted in higher mortality in non-seminoma patients (p=0.005) but not in seminoma patients (p=0.36) where the patient delay was not associated with a more advanced stage.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eBased on our result, we conclude that to improve survival, we should promote testicular cancer awareness, especially among the most deprived populations, and their health care providers.\u003c/p\u003e","manuscriptTitle":"Low Socioeconomic Status is a Risk Factor for Delay to Treatment and Mortality of Testicular Cancer Patients in Hungary. A Prospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-02-26 22:25:42","doi":"10.21203/rs.3.rs-273912/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-03-23T00:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after discretionary revisions\nForm responses:\n---\n\nComments to Author:\n---\nThank you for the opportunity to review this work. I think it was an interesting study with some definite strengths. My comments are provided below to help strengthen the piece:\n\n* You can use more literature on SSS in the background. I understand yuo operationalize it in the Methods but you can use a bit more context to the variable in the beginning. Further, I think PD and DD might deserve the same treatment.\n* Obviously, this is for Hungarians but was there any variation in demographics besides SES/SSS? Any ethnic variation? That might prove to be useful for healthcare service access and social justice issues (potentially).\n* Good Discussion section. I wonder if you could provide some context on the applicability of these findings with other countries? I know you made reference to some but I think a more rounded conversation on exact areas ight be of use for some.\n* Finally, I think you Conclusion can use more teeth. What type of awareness campaigns do you suggest? Awareness about? The disease itself? Navigation to services? You need more here. This was the weakest part of the paper.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"decision","content":"Major revision","date":"2021-03-23T00:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2021-03-12T00:00:00+00:00","index":2,"fulltext":"Recommendation: Reject\nForm responses:\n---\n\nComments to Author:\n---\nThe authors of this article aim to assess the effect of socioeconomic status on the delay of diagnosis and outcome in patients with malignant testicular cancer. Although relatively frequent, testicular cancer is an important cause of cancer and cancer death among young men and socioeconomic status has been associated with more advanced disease at diagnosis and decreased specific survival among testicular cancer patients.\nDespite the importance of the topic, the study is poorly described and the design and the analyses are not clear.\nThe authors define their study as prospective, however they do not mention the mean/median time of observation of the cohort, nor if there were lost to follow-up nor how the follow-up was performed and the causes of death ascertained (were the 14 deaths observed all from testicular cancer? In the abstract is mentioned cancer-specific survival while in statistical section Overall survival). If we assume that the maximum length of follow-up was 45 months (1 January 2016 to September 2019) why some of the survival curves arrive up to over 70 months? And other do not start at time 0? The figures are too small and poorly recognizable, it is not easy to understand what is represented. The number of persons at risk by time interval should be clearly defined for each group and, may be, given that the survival seems not going lower than 60%, the axe of the proportion surviving could start at 0.5.\nIt is not clear the utility of the Mac Arthur Scale as its association with survival or other outcomes is not used. On the other hand, the authors do not explain why they have chosen those three variables (educational level, number of consumer durable goods (?), and size of living area per capita) to calculate their SES index, given that apparently there were several other variables could have been included/chosen.\nThe statistical analysis section is also rather weak. In the abstract the talk about cancer-specific survival not clear how measured (1.56% in the highest vs 13.09% in the lowest SES?) in the statistical section they talk about Overall Survival. How the authors did used the logistic regression to \"correlate\" survival to patient delay? Where are the results and the Odds Ratios? The majority of the results are purely descriptive, there are many variable and some of them are highly correlated and small number of patients in the different groups. No multivariable model has been presented to show the independent effect of the single variables. Why the patient delay is presented by educational level and not by SES. Same choice seem completely arbitrary, should be explained.\nIn the results section they say that 306 patients filled the questionnaire. They do not specify if this number represents the total number of people asked to participate or if there were patients who refused to participate. This information is very useful as could give an idea of the degree of selection of the study population. The description of the population in terms of stage at diagnosis and prognosis is not clear.\nIn the discussion section, the authors say that this study \"includes the prospective data analysis of the socioeconomic status of patients followed or treated with testicular cancer\". But the authors did not follow the socioeconomic status changes of the patients with time. And what do they mean that the patients were followed or treated? This concept is repeated in the conclusion where they say that this is the first study that prospectively evaluated the patients' objective and subjective social statusesand the survival ratios (ratios?).\nThe major deviation found by the authors in terms of higher educational level of the patients compared with the Hungarian average could partially be explained by the selection of patients who participated. The authors say that the association with patient's SES was stronger for patient delay that with doctor delay but the two variables were measured and analyzed in different ways and never together. Again, not clear how the logistic regression has been performed. They also say that patient delay did not influence stage at diagnosis in seminoma but the association was clear with non seminoma, however no results on this point are mentioned or shown.\nThe same definition of socioeconomic status should be used everywhere in the text, but the authors sometime use social quartile, sometime SES indicators, SES index, or objective social status \nThe number of tables and figures is excessive. Some of the results could be combined in the same tables: table 6 and 7 could go with table 1. In table 1 the distribution by stage (I, II, III) could be added. The figure with the Kaplan-Meier curves are almost illegible.\nThe references should be updated.\n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons after the final decision on the manuscript has been made. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **No**\n* Declaration of competing interests: **I declare that I have no competing interests.**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **No**\n* Is the use of statistics and treatment of uncertainties appropriate?: **No**\n* Is the presentation of the work clear?: **No**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewerAgreed","content":"","date":"2021-02-26T00:00:00+00:00","index":2,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2021-02-21T00:00:00+00:00","index":1,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-02-18T00:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2021-02-18T00:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2021-02-17T23:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2021-02-17T23:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2021-01-31T00:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ae1e3249-d07c-432f-92ea-556b2971275f","owner":[],"postedDate":"February 26th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":2633955,"name":"Health Economics \u0026 Outcomes Research"},{"id":2633956,"name":"Infectious Diseases"},{"id":2633957,"name":"Health Policy"}],"tags":[],"updatedAt":"2021-02-26T22:25:42+00:00","versionOfRecord":[],"versionCreatedAt":"2021-02-26 22:25:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-273912","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-273912","identity":"rs-273912","version":["v1"]},"buildId":"ApUGefWb6u5IBVtyqm6d5","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}