Testis Ca care deviates from guidelines in 30% of patients

Author(s):

Nearly one-third of men with testicular cancer undergo diagnostic or therapeutic interventions that are at odds with guidelines from the National Comprehensive Cancer Network (NCCN), according a study published in the Journal of Urology (2017; 197:684-9).

Badar M. Mian, MD

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Kevin Wymer, MD, and co-authors from the University of Chicago; Johns Hopkins University, Baltimore; and the University of Southern California, Los Angeles reported that non-guideline-directed care could be identified in 30% of men with testicular cancer.

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The investigators retrospectively analyzed their pooled data to determine the extent to which testicular cancer care follows the NCCN guidelines. Of the 705 consecutive patients with testicular tumor, 80% had the diagnosis made elsewhere before referral to these centers. After excluding non-germ cell or secondary or benign tumors, 536 patients had detailed records available for analysis.

A mismatch between the documented care and the 2015 NCCN guidelines was noted in 177 patients (30%). Higher likelihood of mismatched care was noted in Hispanic men or those who underwent an orchiectomy at a community site or had pain at presentation or had metastatic disease. The mismatched care was classified into four categories: overtreatment, under-treatment, misdiagnosis, and inappropriate treatment.

Next: Inappropriate imaging noted in 44%

Inappropriate imaging noted in 44%

Among these 177 patients, the most frequent departure from the NCCN guidelines was the use of inappropriate imaging studies in 44% of the men (eg, unnecessary positron emission tomography scan or brain or bone imaging). Overtreatment was noted in 40% of these men, and included either an unnecessary biopsy or unnecessary chemotherapy or inappropriate drug regimen. Misdiagnosis, in terms of delayed diagnosis (antibiotics for presumed infection) or misread imaging studies, occurred in 24%. Under-treatment was detected in 16%, and it was primarily due to too few cycles of chemotherapy.

More importantly, receiving cancer care that was different from the NCCN guidelines was identified as a significant predictor of cancer relapse. As one might expect, the higher risk of relapse was driven by under-treatment (insufficient chemotherapy), which was the strongest predictor of relapse. But other factors such as race (Hispanics) and overtreatment were also associated with increased relapse rate. Co-author Scott Eggener, MD, associate professor of surgery/urologic oncology at the University of Chicago, pointed out that “typically, patients with testicular cancer are young, otherwise healthy, and have a lifetime ahead of them; compromising cure or administering unnecessarily excessive toxicity can have profound consequences.”

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The development of guidelines and standardized care protocols is an enormous task, and those who volunteer their time for these endeavors must be commended. Obvious benefits from the use of these guidelines include reduced variability in care, lower cost, lower morbidity, and improved outcomes. However, while promoting guideline utilization, we must exercise caution in our approach so that every departure from the guidelines is not viewed as harmful or negligent care. Having received fewer-than-recommended chemotherapy cycles/regimen was associated with increased risk of relapse. But the retrospective nature of the report cannot inform us about the reasons for that discrepancy (eg, excessive drug toxicity).

Further, undergoing an extra (or unnecessary) imaging study (eg, PET scan instead of a computed tomography scan) may be quite wasteful on a societal level but not necessarily directly harmful to the individual patient.

Testicular cancer management is often promoted as a triumph of multidisciplinary cancer care through the use of standardized protocols and guidelines. This study, among the first to examine this issue in the United States, provides valuable insight into the need for further improvement in care coordination, education, and dissemination of these standardized protocols.