Assessing Quality of Care in the Diagnosis and Treatment of Early-Stage Testicular Cancer: A Critical Review and Summary - Beyond the Abstract

As cure rates for testicular cancer continue to improve, the focus of care has shifted towards survivorship and minimizing unnecessary treatment toxicities, particularly for men with early-stage disease.1,2 This has resulted in greater emphasis on ensuring the delivery of high-quality care. In this study, we reviewed a selection of articles about quality of testicular cancer care which were identified in a systematic review performed for the American Urological Association guidelines on Diagnosis and Treatment of Early-Stage Testicular Cancer.3


Our study raises a number of important questions related to quality of care. First, we identified substantial evidence that men who receive treatment at high-volume, tertiary centers or from high-volume surgeons have substantially better testicular cancer outcomes and overall survival.4 These findings support the need for greater centralization of care at select centers of excellence. Yet studies have also identified that travel distance between home and care center, as well as other socioeconomic factors such as education, income, and insurance status, are associated with worse outcomes, including decreased patient follow-up and higher stage disease on initial presentation.5 These observations suggest that efforts to centralize care might exacerbate ongoing disparities for those who live more remotely or who do not have ready access to tertiary care centers. 

Of note, a number of studies demonstrate worse testicular cancer outcomes for Black, Hispanic, and Asian patients compared to White patients. Given ongoing efforts to establish more nuanced assessments of the interplay between race and health, additional work is needed to better characterize these disparities and how centralization of care may truly affect testicular cancer outcomes for disparate populations.6 This includes an honest assessment of physician-driven factors, including examining potential differences in how physicians counsel or refer patients based on race. Other possible explanations include differences in environmental exposures, heredity, language barriers, and cultural differences regarding openness to discussing testicular findings. Further research can help explore how these different factors may drive these observed disparities.

Finally, few of the studies that we examined discussed fertility considerations such as sperm banking or counseling about fertility prior to testicular cancer treatment. Given the young age of patients with testicular cancer and the increasing focus on survivorship, fertility assessments, hormonal evaluations, and mental health will likely become a greater point of emphasis in the delivery of high-quality care. These topics are all important considerations in the treatment of testicular cancer patients and should garner increased attention in the immediate future. We hope that our review serves as a guide for future avenues of research focused on the delivery of high-quality care for men with testicular cancer.  

Written by: Mitchell M. Huang, MD and Phillip M. Pierorazio, MD, The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD

References:

  1. Howlander N, Noone A, Krapcho M, et al. SEER Cancer Statistics Review, 1975-2016. Natl Cancer Inst. 2016.
  2. Pierorazio PM, Albers P, Black PC, et al. Non–risk-adapted Surveillance for Stage I Testicular Cancer: Critical Review and Summary [Figure presented]. Eur Urol. 2018. doi:10.1016/j.eururo.2017.12.030
  3. Stephenson A, Eggener SE, Bass EB, et al. Diagnosis and Treatment of Early Stage Testicular Cancer: AUA Guideline. J Urol. 2019. doi:10.1097/JU.0000000000000318
  4. Woldu SL, Matulay JT, Clinton TN, et al. Impact of hospital case volume on testicular cancer outcomes and practice patterns. Urol Oncol Semin Orig Investig. 2018. doi:10.1016/j.urolonc.2017.08.024
  5. Macleod LC, Cannon SS, Ko O, et al. Disparities in Access and Regionalization of Care in Testicular Cancer. Clin Genitourin Cancer. 2018. doi:10.1016/j.clgc.2018.02.014
  6. Flanagin A, Frey T, Christiansen S, Bauchner H. The Reporting of Race and Ethnicity in Medical and Science Journals: Comments Invited. JAMA. 2021. doi:doi:10.1001/jama.2021.2104
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