Reply to the letter to the editor ‘A centralised multidisciplinary clinic approach for germ cell tumours’ by Crawford
Authors: C. Albany, N. Adra, A. Snavely, C. Cary, T. Masterson, R. Foster, K. Kesler, T. Ulbright, L. Cheng, M. Chovanec, F. Taza, N. Hanna, L. Einhorn
Journal: Annals of Oncology (2018)

We would like to thank Dr Crawford, for his comment [1.Crawford SM. A centralised multidisciplinary clinic approach for germ cell tumours.Ann Oncol. 2018; 29: 2263-2264Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar] on our original article [2.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 (48) Google Scholar]. Patients seen in high-volume centers have better outcomes compared with low-volume centers. Due to the rarity of the disease, many oncologists may encounter only a small number of patients each year with advanced testicular cancer. Based upon our experience from reviewing the medical records of referred patients to our center, treatment of some patients is inconsistent with these guidelines. For example, some patients with poor risk disease receive four cycles of etoposide and cisplatin (EP) rather than Bleomycin, etoposide and cisplatin (BEP) (confusing the treatment of good and poor risk disease). We have also observed the common practice of giving unnecessary additional chemotherapy when a computed tomography scan post-chemotherapy showed residual disease despite normal tumour markers. While some patients with residual masses do have active cancer, the majority will have only necrosis or teratoma. These patients are properly managed with retroperitoneal lymph node dissection (RPLND) rather than further chemotherapy. The overtreatment and undertreatment of patients are a relatively frequent occurrence [3.Wymer K.M. Pearce S.M. Harris K.T. et al.Adherence to National Comprehensive Cancer Network(R) guidelines for testicular cancer.J Urol. 2017; 197: 684-689Crossref PubMed Scopus (32) Google Scholar]. The importance of an experienced multidisciplinary team cannot be overemphasized. Surgeries such as RPLND and thoracotomy to remove primary mediastinal germ-cell tumours (GCT) or lung metastasis are complex and require expertise available only at high-volume centers. As indicated by the letter from Dr Crawford, we acknowledge that our report has limitations, including the retrospective nature of the analysis, and an inability to match all patient’s characteristics of IU data versus the SEER database. In addition, we agree entirely that racial and socioeconomic differences are associated with differences in outcome and this could play a role in outcomes. We also acknowledge that these patients can travel to IU and may have socioeconomic differences compared with other patients, contributing to some selection bias. The International Germ Cell Consensus Classification version 2 (IGCCCG V2) is underway with retrospective data on more than 10 000 patients being analyzed, and results are expected in the near future. This will shed more light on the outcome of GCT from high-volume centers and patients treated in clinical trials. Many studies have shown that patients treated at centers of excellence have better survival than small-volume centers [4.Woldu S.L. Matulay J.T. Clinton T.N. et al.Impact of hospital case volume on testicular cancer outcomes and practice patterns.Urol Oncol. 2018; 36 (14e14.e15): 14e17Crossref Scopus (35) Google Scholar,5.Paffenholz P. Heidegger I.M. Kuhr K. et al.Non-guideline-concordant treatment of testicular cancer is associated with reduced relapse-free survival.Clin Genitourin Cancer. 2017; 16: e243-e250Abstract Full Text Full Text PDF Scopus (11) Google Scholar]. Thus, we argue that for these patients central care in high-volume center will result in better overall survival and reduce over or under treatment. We agree with the new European Society for Medical Oncology (ESMO) guidelines recommendations that treatment of patients with GCT should be conducted in high-volume centers [6.Honecker F. Aparicio J. Berney D. et al.ESMO Consensus Conference on testicular germ cell cancer: diagnosis, treatment and follow-up.Ann Oncol. 2018; 29: 1658-1686Abstract Full Text Full Text PDF PubMed Scopus (106) Google Scholar]. An alternative approach would be to attempt to improve this health care disparity in outcomes at low-volume hospitals by incorporating quality measure in every GCT and utilization of telemedicine and consultation of experts. None declared.