Incorporating non-biological factors into the TNM staging system for better prognostication and decision-making in testicular cancer

  • Yongqiang Huang
  • Haoyue Sheng
  • Junyu Zhang
  • Qi Liu
  • Dingwei YeEmail author
  • Guohai ShiEmail author
Original Article



We combined county-level socioeconomic status (SES), marital status and insurance status to introduce NBF-stage, which were further incorporated into the American Joint Committee on Cancer (AJCC) TNM staging system to generate an integrated staging system for better prognostication and decision-making for testicular cancer patients.


15,324 eligible patients diagnosed with primary testicular cancer between January 1, 2007 and December 31, 2015 were strictly selected from the Surveillance, Epidemiology, and End Results (SEER) database. Independent survival predictors were determined based on Cox proportional hazards model. The Kaplan–Meier survival curves were conducted to describe the difference in predicting survival probability and the Multivariate Cox proportion hazard regression analyses were established to compare the cancer-specific survival (CSS) and overall survival (OS) difference among NBF stages or NBF–TNM subgroups.


County-level SES, marital status and insurance status were independent prognostic non-biological factors (NBFs) in our study (P < 0.05). NBF-stage (combination of SES, marital status, and insurance status) was also an independent survival predictor in TC (P < 0.05). NBF1 patients had 167% increased risk of cancer-specific mortality (CSM) as compared to NBF0 patients in testicular cancer (P < 0.01). And NBF0 patients all had a better CSS as compared to NBF1 patients of the same TNM stage both in seminoma and non-seminomatous germ cell tumor (P < 0.05).


Incorporation of NBFs into AJCC TNM staging system in testicular cancer would potentially impact treatment decisions where treatments would not be rendered for a typically curable cancer with multi-modal therapy.


Non-biological factors AJCC TNM stage SEER Testicular cancer, stage I 



Non-biological factor


Testicular cancer


Testicular germ cell tumor


American Joint Committee on Cancer


International Germ Cell Cancer Collaborative Group


Tumor, Node, Metastasis


Socioeconomic status


Surveillance, Epidemiology, and End Results


Cancer-specific survival


Cancer-specific mortality


Human chorionic gonadotrophin




Seminomatous germ cell tumor


Non-seminomatous germ cell tumor


Confidence interval


Seminomatous germ cell tumor


Non-seminomatous germ cell tumors



We thank the Surveillance, epidemiology, and End Results (SEER) program for providing their platforms and contributors for their valuable datasets. This study was funded by the National Natural Science Foundation of China (Grant No. NSFC 81672512).

Author contributions

GS and DY had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: YH, GS. Acquisition of data: HS. Analysis and interpretation of data: JZ, QL. Drafting of the manuscript: YH, QL. Critical revision of the manuscript for important intellectual content: Statistical analysis: YH, HS, QL. Obtaining funding: DY, GS. Administrative, technical, or material support: DY, GS. Supervision: DY, GS. Other (specify): None.

Compliance with ethical standards

Conflict of interest

This paper does not contain any studies with human participants or animals. Informed consent was not needed because the present study based on a publicly available database without identifying patient information. The author has no relevant affiliations or financial conflict with the subject matter or materials discussed in the manuscript. Peer reviewers on this article have no special financial or relationships to declare.

Supplementary material

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Supplementary material 1 (DOCX 13 kb)
345_2018_2603_MOESM2_ESM.docx (13 kb)
Supplementary material 2 (DOCX 13 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of UrologyFudan University Shanghai Cancer CenterShanghaiChina
  2. 2.Department of Oncology, Shanghai Medical CollegeFudan UniversityShanghaiChina
  3. 3.Department of Colorectal SurgeryFudan University Shanghai Cancer CenterShanghaiChina

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