Practice Patterns and Impact of Postchemotherapy Retroperitoneal Lymph Node Dissection on Testicular Cancer Outcomes.

Abstract

Background:

Owing to surgical complexity and controversy regarding indications, there are wide practice variations in the use of postchemotherapy retroperitoneal lymph node dissection (PC-RPLND).

Objective:

To evaluate patterns of PC-RPLND use in the USA and evaluate the association between PC-RPLND and survival in advanced nonseminomatous germ cell tumors (NSGCTs).

Design setting and participants:

A retrospective, observational study using National Cancer Data Base (NCDB) data from 2004-2014 for 5062 men diagnosed with stage II/III NSGCT.

Outcome measurements and statistical analysis:

In a comparative analysis based on receipt of PC-RPLND, the primary outcome of interest was factors associated with omission of PC-RPLND as explored via logistic regression. As a secondary outcome, we evaluated the association between PC-RPLND and overall survival (OS) via multivariable Cox regression and propensity score matching (PSM).

Results and limitations:

Patients undergoing PC-RPLND were more likely to be younger, white, privately insured, and reside in more educated/wealthier regions (p < 0.001). Insurance status was independently associated with receipt of PC-RPLND; compared to patients with private insurance, those without insurance were significantly less likely to receive PC-RPLND (odds ratio 0.49; p < 0.001). After multivariate adjustment, age, comorbidity, non-private insurance, distance from hospital, clinical stage, and risk group were independently associated with all-cause mortality. In addition, omission of PC-RPLND remained associated with all-cause mortality (hazard ratio 1.98; p < 0.001). After PSM, the 5-yr OS was significantly lower among those not undergoing PC-RPLND (72% vs 77%; p = 0.007).

Conclusions:

PC-RPLND represents a critical part of the multidisciplinary management of NSGCT. Patients with non-private insurance are less likely to undergo PC-RPLND, and omission of PC-RPLND is associated with lower OS.

Patient summary:

We evaluated the practice patterns for advanced testicular cancer management and found that patients who did not undergo a postchemotherapy retroperitoneal lymph node dissection were more likely to have worse survival outcomes. Patients with unfavorable insurance were less likely to receive this surgical treatment.

• Authors: Solomon L Woldu, Joseph A Moore, Bo Ci, Yuval Freifeld, Timothy N Clinton, Ahmet M Aydin, Nirmish Singla, Krabbe Laura-Maria, Ryan C Hutchinson, James F Amatruda, Arthur Sagalowsky, Yair Lotan, Yull Arriaga, Vitaly Margulis, Yang Xie, Aditya Bagrodia
• Journal: European urology oncology (Eur Urol Oncol) Vol. 1 Issue 3 Pg. 242-251 (08 2018) ISSN: 2588-9311 [Electronic] Netherlands
• PMID: 31058267 (Publication Type: Journal Article, Observational Study, Research Support, N.I.H., Extramural, Research Support, Non-U.S. Gov't)

Topics

• Adult
• Antineoplastic Combined Chemotherapy Protocols (therapeutic use)
• Combined Modality Therapy
• Humans
• Lymph Node Excision (methods)
• Lymphatic Metastasis
• Male
• Neoplasm Recurrence, Local (surgery)
• Neoplasms, Germ Cell and Embryonal (drug therapy, mortality, pathology, surgery)
• Practice Patterns, Physicians' (statistics & numerical data)
• Retroperitoneal Space (surgery)
• Retrospective Studies
• Survival Analysis
• Testicular Neoplasms (drug therapy, mortality, pathology, surgery)
• Treatment Outcome
• Young Adult