Testicular cancer is the most common malignancy among young men and well-established treatment guidelines exist to optimize outcomes. We characterized errors in the management of testicular cancer observed among patients seen at three referral centers in the United States.
We retrospectively reviewed data from 593 patients presenting with testicular cancer to three academic medical centers from 2007-2016. Non-guideline directed care (NGDC) was defined as management differing from National Comprehensive Care Network (NCCN) Guideline recommendations. Cases of NGDC were systematically described. Patient and tumor characteristics were compared between guideline directed care (GDC) and NGDC. Multivariable logistic regression was used to identify predictors of NGDC and Cox regression modeling was used to assess the association between NGDC and relapse-free survival.
NGDC was identified in 177/593 (30%) patients. Inappropriate imaging (44%) and overtreatment (40%) were the most common. Misdiagnosis (24%) and undertreatment (16%) were relatively frequent, while inappropriate treatment (6%) was rare. On multivariable analysis, risk factors for NGDC included metastatic disease (OR= 2.17, p<0.01), presentation with testicular pain (OR= 1.89, p=0.02) or metastatic symptoms (OR= 4.60, p<0.01), and diagnosis at a low-volume center (OR=3.46, p<0.01). Undertreatment was found to be a significant predictor of disease relapse (HR=3.36, p<0.01).
NGDC of patients with testicular cancer is common, most frequently inappropriate imaging and overtreatment. NGDC leads to delayed definitive therapy, unnecessary morbidity, and higher rates of relapse. Risk factors for NGDC include metastatic disease, presentation with testicular pain, symptoms from metastases, and diagnosis at a low volume center.
The Journal of urology. 2016 Sep 20 [Epub ahead of print]
Kevin M Wymer, Shane M Pearce, Kelly T Harris, Phillip M Pierorazio, Siamak Daneshmand, Scott E Eggener
Pritzker School of Medicine, University of Chicago, Chicago IL., Section of Urology, Department of Surgery, University of Chicago, Chicago IL., The James Buchanan Brady Urological Institute, The Johns Hopkins University School of Medicine, Baltimore MD., Institute of Urology, USC/Norris Comprehensive Cancer Center, University of Southern California Keck School of Medicine, Los Angeles CA., Section of Urology, Department of Surgery, University of Chicago, Chicago IL. Electronic address: .