A centralised multidisciplinary clinic approach for germ cell tumours
Authors: S.M. Crawford
Journal: Annals of Oncology (2018)

The article by Albany and colleagues from Indiana University (IU) draws attention to the excellent survival outcomes in metastatic germ cell tumours treated in the institution [1.Albany C. Adra N. Snavely A.C. et al.Multidisciplinary clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors.Ann Oncol. 2018; 29: 341-346Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar]. They attribute their success to the work of their multidisciplinary team. Whilst I do not doubt the value of this approach, I question whether their methodology accurately determines its magnitude. Morris et al. drew attention to the pitfalls in comparing outcomes between individual institutions [2.Morris M. Quaresma M. Pitkäniemi J. et al.Do cancer survival statistics for every hospital make sense?.Lancet Oncol. 2016; 17: 1192-1194Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. Of relevance to the Indiana University report is the fact that a cohort of patients referred from afar cannot be assumed to be the same. The authors emphasise that they are reporting on patients whose chemotherapy was initiated in IU but their map, presented as a supplementary figure, shows patients’ provenance from all over the Eastern half of the USA including large cities such as Chicago, IL and New York, NY where there are highly reputable cancer centres which offer multidisciplinary care. Patients from these areas who are able to choose IU as their care provider will have characteristics of fitness to travel, ability to afford to do so and ability to assess information about hospitals including the long-established and well-deserved reputation of IU in this field. These characteristics themselves maybe associated with superior outcomes. Even within the State of Indiana in settlements distant from Indianapolis patients with favourable characteristics may choose to travel there, the map shows that many did, whereas those from across town who lack these characteristics will stay with the local clinic to form the ‘SEER distant’ cohort. Furthermore, they state that the main selection criterion for the IU cohort was initiation of first-line chemotherapy there. The SEER distant cohort merely had to have recorded survival >0. It is not stated that they had to be fit enough for chemotherapy, let alone receive it. The authors suggest that the size of their sample of consecutive patients is sufficient to overcome this referral bias. It is not clear why this is so. They give little information about the SEER distant cohort and explain the limitations of the different staging systems, but why did they not report the IU cohort staging the same way as SEER? The one point of comparison they report is the ethnicity; 97% IU sample of 704 were white, 87% SEER sample of 1283 were white. The difference is 10% (95% CI 7.8–12.3) and in the USA racial differences seem to be a surrogate for socioeconomic differences which are associated with differences in outcome. The IU team are to be congratulated for their many achievements in germ cell tumour management but in constructing health delivery models to enhance value and improve clinical outcomes a centralisation of services in a way that makes them inaccessible to many patients is to be avoided. It would be inappropriate to use this analysis to make a case for such changes. None declared.