It’s Doctor Expertise That Counts with Testicular Most cancers

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It’s Physician Experience That Counts with Testicular Cancer

One in 270 men will develop testicular cancer, the most common malignancy in men between the ages of 20 and 40, according to Johns Hopkins Medicine. A diagnosis of cancer is never something someone wants to hear, and they may have as many questions as, "What type of cancer?", "How far has it spread?" and "Do I get the best care?" The good news is that research from the University of Texas Southwestern has shown that the place where you get your treatment, be it a tertiary or safety net hospital, may not be as important as the team treating you.

Tertiary hospitals offer their patients the most advanced and specialized care. A safety net hospital is the opposite; You must treat all patients regardless of their solvency. However, they may not have the specialized facilities of a tertiary center.

The study

A team of doctors from UT Southwestern were engaged in a natural experiment. The multidisciplinary team of oncologists, urologists and pathologists worked at UT Southwestern Hospital, a tertiary center, and Parkland, a public hospital in Dallas and a safety net hospital. "It's pretty obvious when you walk through the door and only work in these places that the patient populations are very different," said Dr. Aditya Bagrodia in an interview with Medical Daily. Dr. Bagrodia is a urologist and part of the multidisciplinary team that is the focus of the study.

The team's clinicians compared notes on patients with testicular cancer treated at either center and their results. "Not unexpectedly certain demographic factors, a lack of insurance, a lack of education, a lack of health literacy and minority status are linked to the worst clinical outcomes in many different areas," said Dr. Bagrodia. "The idea was that (if) we really do the exact same thing for these very different patient populations, we can level the playing field by providing expert care on a large scale."

The patients

The study, published in August in the journal Cancer, tracked 201 patients treated between 2006 and 2018. 106 from Parkland Hospital and 95 from UT Southwestern. The men were between 24 and 41 years old, with the Parkland group being slightly younger on average. Men from the Parkland group were also more likely to be Spanish and less insured.

Despite these differences, the study's authors reported that patients generally received the same care. Both groups received orchiectomies, operations to remove the testicles. The Parkland group had an average of one day less time between diagnosis and surgery, while the UT Southwestern group waited an average of 4 days.

And their results

The Parkland patients often had advanced cancer at initial diagnosis compared to the UT Southwestern group. Using the American Joint Committee on Cancer Staging for Testicular Cancer, where Stage I is the earliest and Stage III is the most advanced, 70 men in the UT Southwestern group had Stage I disease, 16 had Stage II, and 9 had Stage III . Among the parkland men, 62 had Stage I, 20 had Stage II, and nearly a quarter, 24 men had Stage III. Despite the differences, both groups were equally likely to receive treatments such as surgery or chemotherapy.

According to statistics from Johns Hopkins Medicine, around 400 men die from testicular cancer each year, which means that only 1 in 5,000 men diagnosed will die from testicular cancer. Four men died in the parkland group. All had come first with stage III cancer and for 3 with the cancer that had metastasized to the brain.

Early diagnosis is key

Three quarters of patients who went to Parkland were seen in the emergency room first, while barely a tenth of UT Southwestern patients went to the emergency room first. The UT Southwestern patients reported to a doctor an average of 31 days after symptoms appeared, while the Parkland patients waited an average of 65 days, more than twice as long. Dr. Bagrodia had some ideas about the delay, although that wasn't the main focus of the study. He theorized that lack of insurance, concerns about immigration status, inability to work freely, or problems with childcare could delay patient entry. "We can only look after you as best as possible at short notice if you come to us and you go through the door," he said.

"Historically, there is a saying in urology that the sun never sets on testicular cancer," added Dr. Bagrodia added. "Basically, this means that as soon as a patient walks in, they are located immediately because they can (have) rapidly progressing tumors and, like so many types of cancer, show variable behavior." Dr. Bagrodia was not as definitive as to whether or not the 34-day difference in patient groups mattered. He stated that "… early diagnosis, treatment and detection of the problem at both the patient and clinician level is absolutely critical."

Can these insights go beyond Texas?

This study looked at only two Texas hospitals where the results were surprisingly similar in very different populations. Could this be true anywhere else? Yes and no, according to Dr. Bagrodia. He explained that part of the model is not uncommon: “(T) His model of the same group of doctors caring for people in a tertiary cancer center as well as a safety net hospital is not very common, but it is not super unusual either. "It's shared by hospitals in California, Georgia, and Tennessee, to name a few. However, the patients in this study not only had the same doctors, they also had a group of doctors."

"In total, there are approximately 9,000 testicular cancer cases in the US each year," he continued. This means that doctors don't always have a lot of experience treating the disease. "It's complex and nuanced and requires multidisciplinary teams," he said. Different doctors, practitioners and support structures are necessary to ensure the best care. UT Southwestern has both a multidisciplinary group of doctors and the group that treats the tertiary center and the safety net center, which makes this a special situation.

Is the care really the same?

"Sometimes you have to have surgery to remove lymph nodes that have metastatic cancer cells … and when done correctly, you can usually spare the nerves that allow a patient to maintain their ejaculatory function," said Dr. Bagrodia. "Things like that are done whether you have an operation in Parkland or UT Southwestern." Other costs for things like prosthetics, sperm banking (which Dr. Bagrodia said could be as high as $ 300 a year), and assisted reproductive technology when a couple wants to use sperm are not in the hands of the team. The UT Southwestern men used these services far more frequently than the Parkland men. The procedures are not medically compulsory and not always insured.

Despite the similarities in hospital care, the economic differences between UT Southwestern and Parkland have not gone away. "I would love to offer sperm banking and prostheses to all patients, but until there are some system-wide initiatives to make them compulsory, I'm just not sure if this can become a reality."

What do the study results mean?

For the patient, the results are a good thing. You don't have to go to the best hospital with the most resources to get good care. It is more important that you receive early care. Although this study did not compare the care provided by the team to an individual practitioner, a doctor who practices alone rather than as part of a team, this multi-expert model with many opinions and support could be part of the success of UT Southwestern.

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