Zip code, race, and ethnicity: The impact of socioeconomic hardship on cancer presentation and survival among patients with testicular germ cell tumors

Introduction and objectives Testicular germ cell tumors (GCTs) are highly curable when diagnosed at early stages. Despite effective treatments, disparities in socioeconomic status (SES) play a significant role in cancer outcomes. We aim to explore the impact of the hardship index (HI), a composite metric encompassing factors such as poverty levels, per capita income, unemployment rates, educational attainment, housing density, and the dependency ratio (the proportion of young and elderly individuals), on patient presentation and survival rates. Methods We conducted a county-wide audit of all GCT cases diagnosed in Bexar, Texas, from 2012 to 2023. For cancer stage analysis, logistic regression was utilized using HI, insurance status, and distance to hospital. Cox proportional hazards (COX) models and Kaplan–Meier (KM) analyses were employed to estimate the impact of the HI on progression-free survival (PFS) and overall survival (OS). Lower HI scores indicate greater socioeconomic hardship. Results Of the 645 subjects, 297 GCT met the inclusion criteria. Neither age nor race/ethnicity (non-Hispanic White/Black, Hispanic, Other) was associated with late-stage diagnosis (Stages II–III). Greater hardship was significantly associated with late-stage diagnosis (OR: 1.02 per unit decrease, 95% CI: [1.01, 1.03], P = 0.002). Patients without insurance (OR: 2.30, P ' 0.001) and those with greater distance to hospital (OR: 1.07 per mile, P = 0.001) were also more likely to present with late-stage disease. Uninsured patients had significantly longer treatment delays (median: 83 vs. 40 days, P = 0.034). Furthermore, Cox analysis revealed that patients with greater hardship (scores ≤30) had a higher risk of progression (HR: 4.10, P = 0.0019). KM analysis demonstrated poorer PFS for the greater hardship group overall (P = 0.006) and for NSGCT patients (P = 0.0063), with no significant difference for seminoma patients (P = 0.43). Conclusions When GCTs are assessed comprehensively by evaluating socioeconomic hardship, those with greater hardship were more likely to present with late-stage diagnosis and have poorer PFS. Uninsured patients and those living farther from care are at higher risk for advanced-stage presentation. By comprehensively addressing economic, educational, and geographic barriers, early diagnosis and avoidance of toxic curative therapy may be achievable for this highly treatable disease, even in advanced stages. Interventions targeting these barriers could ultimately improve survival outcomes.