The hypothesis and underpinning of this talk are that there is a clinically significant decrement in GCT patient outcomes in low-experience / low-volume centers. He wants to explore ways to improve or eradicate the outcome gap between high and low volume centers.
- There is recognition that inferior outcomes are common and multifactorial, but primarily appear related to lack of experience in this uncommon disease
- There is also recognition that we are in a phase where we are maxing out on treatments and that major progress will likely be a result of systems changes and improved/innovative health care delivery initiatives
Dr. Nichols doesn’t believe that we are likely to improve much on the current chemotherapy backbone. Clear directionality of the data suggests lower cure rates, higher costs, and more toxicities are associated with low experience centers. These performance gaps are particularly felt in rural, poor, and minority populations – and in developing countries. “Finishing” what was started was ensuring the excellent outcomes achieved in centers of excellence is translated to the general population.
He provided some data to highlight the discrepancies:
- Jeldres et al (ASCO 2014) – using NCDB, they found that 93% of patients are treated in centers that manage <20 cases of testicular cancer each year! Treatment at high volume centers was associated with significant OS benefit.
- Indiana University (Annals Oncology 2017) compared their outcomes from 1998-2014 to the SEER dataset from 2000-2014. They found that while 5-year OS for all testis cancer patients was 90%, it was 75% in the SEER database.
- SWENOTECA data (report pending), a national study in Sweden and Norway, demonstrated a 10% improvement in 10-year overall survival rates from the 1980’s to 1990’s with the introduction centralized coordination of care.
How to address this problem?
- Too costly and not practical to require or mandate that all patients be managed at high volume centers
- Unfortunately, even referral to fellowship trained urologists and medical oncologists don’t always guarantee that guidelines are followed – as adherence is low and interpretation can be difficult
- Poor risk patients
- Post-chemotherapy RPLND
- Complex pathology review
- Management of recurrent/refractory disease
His main summary points are below:
- Experience matters in the management of GCTs (and other uncommon curable malignancies)
- Encouraging or mandating referral to high volume centers is self-serving and impractical for all patients
- Patients and local providers much prefer care in their communities, if feasible
- Current technology and care patterns allow for broad information and knowledge exchange at very low cost
- Our attention needs to turn to delivering the promise demonstrated in management seen in high volume centers to all patients with GCTs
- Other large systems (such as in Sweden/Norway) mandate collaboration, selective triage and oversight between expert centers, community providers and patients to achieve a superb outcome – we need to do the same!
- Collaborative efforts are needed to address this gap in care delivery!
Presented by: Craig R. Nichols, MD, FACP, FASCO - Testicular Cancer Commons and SWOG Group Chair's Office
Written by: Thenappan Chandrasekar, MD (Clinical Instructor, Thomas Jefferson University) (twitter: @tchandra_uromd, @JEFFUrology) at the 2019 American Society of Clinical Oncology Genitourinary Cancers Symposium, (ASCO GU) #GU19, February 14-16, 2019 - San Francisco, CA