Institutional experience, hospital and physician volume have been associated with improved outcomes. However, there are little reports in term of impact of multidisciplinary cancer care. Investigation of the role of multidisciplinary clinic in improving the outcomes of patients with metastatic germ-cell tumours (GCTs) at high volume cancer center led to observed better survival compared with the historical International Germ Cell Cancer Collaborative Group (IGCCCG) and the US National Cancer Institute (NCI) Surveillance, Epidemiology, and End Results (SEER) distant cohort. The results are published in the Annals of Oncology.
The optimal management of GCTs is complex, with options including chemotherapy and surgery. The Indiana University Cancer Center established a multidisciplinary clinic to evaluate newly diagnosed GCT patients and those who need additional consultation. The goals of this multidisciplinary clinic are to provide state-of-the-art cancer care and to educate patients, their families, medical students, residents, and fellows in training. This multidisciplinary clinic integrates dedicated team including medical oncologists, pathologists, urologic and thoracic surgical oncologists, full-time coordinator (responsible for data acquisition, scheduling, and following-up with patients and referring physicians) and oncology nurses. The team meets on a weekly basis in a multidisciplinary tumour board. Through this clinic, it is possible to establish the accurate pathologic diagnosis, offer combination chemotherapy, surgical resection of residual tumour and enroll patients on clinical trials all in one visit.
The study authors commented that recent outcome data from large datasets are missing, and the difference in results of patients treated in large volume centers and community centers is unknown. They report survival outcomes in patients with metastatic GCT treated at their multidisciplinary clinic since the publication of IGCCCG and compare the outcome to those of SEER programme. It is the largest single-institution study evaluating survival outcomes of patients with metastatic GCT.
In particular, they conducted a retrospective analysis and identified 1611 patients, of whom 704 patients received an initial evaluation in their multidisciplinary clinic and started first-line chemotherapy. These 704 patients were eligible for analysis. All patients in this cohort were treated with cisplatin–etoposide-based combination chemotherapy. The study team compared the progression-free survival (PFS) and overall survival (OS) of patients treated at their centre with that of the published IGCCCG cohort. The OS of the testis cancer primary cohort in their institution (622 patients) was further compared with the SEER data of 1283 patients labelled with ‘distant’ disease.
With a median follow-up of 4.4 years, patients with good, intermediate, and poor risk disease by IGCCCG criteria treated at their institution had 5-year PFS of 90%, 84%, and 54% and 5-year OS of 97%, 92%, and 73%, respectively. The 5-year PFS for all patients in their cohort was 79%. The 5-year OS for their cohort was 90%. Their cohort had 5-year OS 94% vs 75% for the SEER ‘distant’ cohort between 2000 and 2014 (p < 0.0001).
Several factors may account for excellent survival outcomes seen in this study compared with the IGCCCG and SEER database. This could be attributed to the uniform utilisation of cisplatin–etoposide-based combination chemotherapy, improvement in supportive care avoiding delays between cycles, expertise in post-chemotherapy surgical resection of residual disease and the experience resulting from a large volume of patients. Their multidisciplinary team has specific academic interest in GCT supported by strong research and clinical trials.
The analysis has also limitations. It is a retrospective single institution study. The study team did not have access to matched patient’s characteristics between the contemporary cohort in their centre and the historical IGCCCG cohort, and the community patients reported in SEER. Referral bias might have affected the results of this study. However, this study has a large sample size of consecutive patients with metastatic GCT treated at a tertiary care center with long follow-up. A large portion of patients enrolled in the study had poor risk disease 25.7% compared with 14% of patients from the IGCCCG. Besides, a limitation of this study is that NCI SEER uses a staging system including local, regional, and distant metastases which are not typically used in GCT. The IGCCCG classification of good, intermediate, and poor risk is not included in the SEER database which makes further analysis not possible. It is why the study team compared all patients with metastatic disease as one group.
In this modern cohort of newly diagnosed patients with metastatic GCT, there was an improvement in PFS and OS for good, intermediate, and poor-risk disease compared with IGCCCG. Furthermore, the study team demonstrated that a multidisciplinary team care approach is associated with improved survival outcomes.