Wednesday, April 21

It’s Physician Experience That Counts with Testicular Cancer


One in every 270 men will get testicular cancer, the most common malignancy for men between the ages of 20 and 40, according to Johns Hopkins Medicine. A cancer diagnosis is never something anyone wants to hear and they may have so many questions, like, “What kind of cancer?”, “How far has it spread?” and “Am I getting the best care?” The good news is research from the University of Texas Southwestern found that where you get your treatment, whether it be a tertiary or safety net hospital, may not be as important as the team that is treating you. 

Tertiary care hospitals provide the most advanced and specialized level of care to their patients. A safety net hospital is the opposite; they must treat all patients regardless of their ability to pay. They might not, however, have the special facilities of a tertiary care center. 

The study

A team of doctors at UT Southwestern found themselves in a natural experiment. The multidisciplinary team of oncologists, urologists and pathologists worked at both the UT Southwestern hospital, a tertiary center, and Parkland, a Dallas public hospital and a safety net hospital. “It’s pretty obvious when you walk in the door and just work at these places that they’re very different patient populations” Aditya Bagrodia, MD, said in an interview with Medical Daily. Dr. Bagrodia is a urologist and part of the multidisciplinary team at the heart of the study. 

The clinicians on the team compared notes on patients with testicular cancer who were treated at either of the two centers and their outcomes. “Not unexpectedly certain demographic factors, lack of insurance, lack of education, lack of health literacy, minority status are associated with worst clinical outcomes in many different areas,” Dr. Bagrodia said. “The idea was, [if] we’re really doing the exact same thing for these very different patient populations, are we able to level the playing field by offering high volume expert care.” 

The patients  

The study, published in August in the journal Cancer, followed 201 patients treated between 2006 and 2018; 106 from the Parkland hospital and 95 from UT Southwestern. The men were between 24 and 41 years old, with the Parkland group averaging slightly younger. Men from the Parkland group were also more likely to be Hispanic and less likely to be insured. 

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

And their outcomes  

The Parkland patients often had advanced cancer when they were first diagnosed, compared with the UT Southwestern group. Using the American Joint Committee on Cancer staging for testicular cancer, where stage I is the earliest and stage III 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 like surgery or chemotherapy. 

Around 400 men die each year from testicular cancer, meaning that only one in every 5,000 men diagnosed will die of testicular cancer, according to statistics published by Johns Hopkins Medicine. Four men died in the Parkland group.  All had first arrived with stage III cancer and for 3, the cancer that had metastasized to the brain.

Early diagnosis is key 

Three-quarters of the patients who went to Parkland were first seen in the emergency department, whereas barely a tenth of the UT Southwestern patients went to the ED first. The UT Southwestern patients, on average, checked in with a doctor 31 days after they noticed symptoms, while the Parkland patients waited an average of 65 days, over twice as long. Dr. Bagrodia had some ideas about the delay, although it wasn’t the primary focus of the study. He theorized that lack of insurance, worries about immigration status, inability to get time off work, or childcare issues could delay patients coming in. “All we can do in the short term is give them the best possible care when they come to see us and they walk in the door,” he said.

“Historically there’s a saying in urology, that the sun never sets on testes cancer,” Dr. Bagrodia added. “Basically that means as soon as a patient comes in, that you get them situated, squared away immediately because they can [have] rapidly progressing tumors and, just like so many cancers, they also do display variable behavior.” As to whether or not the 34-day difference in the patient groups mattered, Dr. Bagrodia wasn’t as definitive. He explained that “ …early diagnosis, treatment, recognition of the problem, both at the patient level and the physician level, is absolutely critical.” 

Can these findings go beyond Texas?

This study only looked at two hospitals in Texas, where outcomes were surprisingly similar across very different populations. Could this be true elsewhere? 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 physicians taking care of people at a tertiary cancer center, as well as a safety net hospital, is not super common, but it’s also not super uncommon.” It is shared by hospitals in California, Georgia and Tennessee to name a few. But the patients in this study didn’t just have the same doctors, they also had a group of doctors.

“All together there are about 9,000 cases of testicular cancer annually in the United States,” he continued. That means doctors don’t always have a lot of experience treating the disease. “It’s complex and it’s nuanced, and it does require multidisciplinary teams,” he said. Different physicians, practitioners and support structures are necessary to provide the best care. UT Southwestern has both a multidisciplinary group of doctors and the group treats the tertiary center and safety net center, making this somewhat of a special situation. 

Is the care truly equal? 

“Sometimes you have to do a surgery to remove lymph nodes that have metastatic cancer cells…and when it’s done properly, you can usually spare the nerves that allow a patient to preserve their ejaculatory function,” Dr. Bagrodia explained. “Those types of things are done regardless of whether you’re having your surgery at Parkland or UT Southwestern.” But other costs for things like prosthetics, sperm banking (which Dr. Bagrodia said could be as much as $300 a year) and assisted reproductive technology if a couple wanted to use banked sperm, are out of the team’s hands. The UT Southwestern men were far more likely to use these services over the Parkland men. The procedures are not medically mandatory and not always covered by insurance though.

Despite the similarities in hospital care, the economic disparities between UT Southwestern and Parkland haven’t gone away. “I would love to offer sperm banking and prostheses to all patients but until there’s some types of system wide initiatives to get them covered by insurance I’m just not sure those can be a reality.” 

What do the study findings mean? 

For patients, the findings are a good thing. You don’t need to go to the best hospital with the most resources to get good care. What is more important is that you get care early. Although this study did not compare team delivered care with a solo practitioner, a physician who practices alone, not as part of a team, this model of multiple experts with lots of opinions and support, could be part of UT Southwestern’s success. 

 

 





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