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Eliminating Socioeconomic Disparities in Care for Patients with Testicular Cancer

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Patient Care; Population Science; Genitourinary Cancer

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Researchers at UT Southwestern are investigating the impact of the standardization of care and access to highly specialized professionals across different hospitals with different populations.

Numerous studies have demonstrated that sociodemographic factors, such as minority ethnicity, lower income, lack of adequate health insurance, and undocumented immigration status, negatively impact the detection, treatment, and survivorship of many types of cancer. [1,2] This is also true for patients with germ cell tumors – most commonly testicular cancer – which are the focus of my clinical practice and research. [3]

For more than four years, I have been working at two neighboring hospitals in Dallas – UT Southwestern Medical Center, a large academic tertiary care center, and Parkland, a public safety-net hospital. Although both hospitals have state-of-the-art facilities, they serve very different patient populations. At UT Southwestern the majority of patients are privately insured, and many are often referred from other centers outside the area, while at Parkland the patients are largely uninsured or underinsured.

Over the past 15-plus years, a multidisciplinary disease-oriented team, including urologists, medical oncologists, radiation oncologists, and genitourinary pathologists, has served both clinical locations and patient populations, rotating between hospitals to provide in-person care and surgeries. During our team meetings, we review cases from both locations simultaneously. Thus, we have a valuable opportunity to investigate the impact of the standardization of care and access to highly specialized professionals across different hospitals with different populations.

“When we assessed practice patterns and classical outcome for testicular cancer, including the number of follow-up visits, rates of offering chemotherapy and/or complex surgeries when needed, and recurrence and mortality rates, we found no significant differences between patient groups treated at the two hospitals.”

Aditya Bagrodia, M.D.

Tracking the Data

Leveraging this long-standing collaboration between UT Southwestern and Parkland, we hypothesized that variations in sociodemographic and patient factors between hospital populations could be overcome through standardized treatment of testicular cancer. [4] We searched our electronic medical records for patients who underwent the initial pathological diagnosis and treatment, most commonly orchiectomy (surgical removal of the testicle), for a germ cell tumor at Parkland or UT Southwestern between September 2006 and November 2018 – over 12 years.

Overall, we identified 201 patients diagnosed with testicular cancer, 106 treated at Parkland and 95 at UT Southwestern. On average, patients at Parkland were younger (median age 29 vs. 33 years), more likely to be Hispanic (79% vs. 11%), less likely to be insured (20% vs. 88%), more likely to present at the emergency department rather than to a primary care physician (76% vs. 8%), experiencing symptoms more than twice as long before seeking care (65 vs. 31 days), and more likely to have metastatic (stage 2 or 3) disease (42% vs. 26%) than patients at UT Southwestern.

Noticing the Differences in Care

When we assessed practice patterns and classical outcome for testicular cancer, including the number of follow-up visits, rates of offering chemotherapy and/or complex surgeries when needed, and recurrence and mortality rates, we found no significant differences between patient groups treated at the two hospitals.

When men are diagnosed with testicular cancer, especially those without insurance, we admit them to the hospital right away, rapidly obtain CT scans and laboratory work that day, and conduct the surgery the same day or the next day. On average, men who were treated at Parkland received an orchiectomy, which is first-line treatment for testicular cancer, within one day of diagnosis. This is a strategy that our team has intentionally adopted at Parkland to help overcome socioeconomic differences and reduce healthcare inequality.

This rapid mobilization of care prevents treatment delays that can occur, for example, if patients are unable to schedule time off work at a future date. An equally important component of this work is the committed hospital administration that expedites the logistics and necessary paperwork, so we can provide the appropriate care efficiently.

However, other factors still differed between the patient groups. Rates of sperm banking and testicular prosthesis were lower at Parkland than UT Southwestern; this is likely attributable to the high costs associated with these options, and patient use of these options may have also contributed to the longer time to orchiectomy for patients at UT Southwestern.

The Importance of Experience

This study was recently published in Cancer. [4] While the findings may not surprise medical professionals, it is important for physician-scientists to provide solid evidence and quantify prior assumptions. By doing so, we are then able to effectively pursue socioeconomic factors affecting health outcomes, ensuring patients receive optimal care regardless of their socioeconomic status.

This new data also highlights the importance of having experienced clinicians, who see a high volume of rare cases, working at safety-net hospitals and community hospitals that would typically have less experience with these conditions. While many safety-net hospitals are affiliated with major academic medical centers, those that are not may connect with experienced providers through other means. [5,6] For example, the COVID-induced expansion of telehealth provides a mechanism of additional virtual consultation, [7] and in Germany, there is a very successful rapid consultation program in which physicians can electronically submit a case along with pathology and imaging results and other information for review by experienced experts and receive a timely response. [8]

About the Author

Aditya Bagrodia, M.D., is an Assistant Professor in the Department of Urology at UT Southwestern Medical Center, where he is the Dedman Family Scholar in Clinical Care. Dr. Bagrodia has conducted extensive research in urologic oncology, primarily in biomarker profiles and molecular signatures of urologic tumors as predictors of clinical outcomes. He is funded through competitive grants from the Cancer Prevention and Research Institute of Texas (CPRIT), intramural research grants, and the National Institutes of Health.

Do you have a question about a germ cell tumor case?

Email me directly at aditya.bagrodia@utsouthwestern.edu.

Footnotes

1. Lerro CC, Robbins AS, Fedewa SA, Ward EM. Disparities in stage at diagnosis among adults with testicular germ cell tumors in the national cancer data base. Urol Oncol Semin Orig Investig. 2014;32(1):23.e15-23.e21. doi:10.1016/j.urolonc.2012.08.012
2. Markt SC, Lago-Hernandez CA, Miller RE, et al. Insurance status and disparities in disease presentation, treatment, and outcomes for men with germ cell tumors. Cancer. 2016;122(20):3127–3135. doi:10.1002/cncr.30159
3. Woldu SL, Bagrodia A. Update on epidemiologic considerations and treatment trends in testicular cancer. Curr Opin Urol. 2018;28(5):440-447. doi:10.1097/MOU.0000000000000532
4. Chertack N, Ghandour RA, Singla N, et al. Overcoming sociodemographic factors in the care of patients with testicular cancer at a safety net hospital. Cancer. 2020;126(19):4362–4370. doi:10.1002/cncr.33076
5. Macleod LC, Cannon SS, Ko O, et al. Disparities in Access and Regionalization of Care in Testicular Cancer. Clin Genitourin Cancer. 2018;16(4):e785–e793. doi:10.1016/j.clgc.2018.02.014
6. Albany C, Adra N, Snavely AC, et al. Multidisciplinary clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors. Ann Oncol. 2018;29(2):341–346. doi:10.1093/annonc/mdx731
7. Wosik J, Fudim M, Cameron B, et al. Telehealth transformation: COVID-19 and the rise of virtual care. J Am Med Informatics Assoc. 2020;27(6):957–962. doi:10.1093/jamia/ocaa06
8. Gesundes Kinzigtal - Gemeinsam aktiv fuer Ihre Gesundheit. https://www.gesundes-kinzigtal.de/. Accessed November 6, 2020.

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