title: Do Referral Patterns in Adolescents and Young Adults with Testicular Cancer Impact Oncologic Outcomes?
abstract: Oncologic outcomes in advanced testicular cancer (TC) depend on appropriate and timely care. Often this care is referred to tertiary academic medical centers (AMCs). The aim of this study was to compare oncologic outcomes of adolescent and young adult (AYA) patients with TC treated from the outset at an AMC to those whose care was initiated elsewhere with subsequent referral.
  
  
  
  An institutional TC database was reviewed, and those AYA patients initiating TC care either inside or outside an AMC were compared. Patients were classified as initiating care outside if they had any non-orchiectomy surgery, chemotherapy, or radiotherapy for TC outside an AMC.
  
  
  
  A total of 183 patients were reviewed, of whom 59 initiated TC care outside and 124 were managed initially at an AMC. Patients initiating care outside were more likely to have non-seminoma histology and more often presented with metastatic disease (Stage II [30.5%] or III [35.6%] vs. Stage II [19.4%] or III [19.4%]; p = 0.007). Lower 3-year event-free survival (EFS) was observed in those initiating treatment outside an AMC (60.6% vs. 78.7%; p = 0.027). However, on multivariate analysis adjusting for stage and histology, the location of initiating TC care was no longer significant (hazard ratio = 1.5, 95% confidence interval 0.8-2.9).
  
  
  
  AYA patients initially treated for TC in the community and subsequently referred to an AMC were initially observed to experience worse EFS than those who were managed at an AMC from the outset. However, on multivariate analysis, these findings were largely explained by referral bias, where AYA patients with advanced disease were more likely to be referred to AMCs.
authors.affiliation: 1 Division of Urologic Oncology, University of Texas Southwestern Medical Center , Dallas, Texas.|2 Department of Surgery, Division of Urology, University of Colorado School of Medicine , Aurora, Colorado.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Cost
authors.affiliation: 2 Department of Surgery, Division of Urology, University of Colorado School of Medicine , Aurora, Colorado.
authors.forename: Brian T
authors.initials: BT
authors.lastname: Caldwell
authors.affiliation: 1 Division of Urologic Oncology, University of Texas Southwestern Medical Center , Dallas, Texas.
authors.forename: Mehrad
authors.initials: M
authors.lastname: Adibi
authors.affiliation: 1 Division of Urologic Oncology, University of Texas Southwestern Medical Center , Dallas, Texas.
authors.forename: Ganesh V
authors.initials: GV
authors.lastname: Raj
authors.affiliation: 1 Division of Urologic Oncology, University of Texas Southwestern Medical Center , Dallas, Texas.
authors.forename: Arthur I
authors.initials: AI
authors.lastname: Sagalowsky
authors.affiliation: 1 Division of Urologic Oncology, University of Texas Southwestern Medical Center , Dallas, Texas.
authors.forename: Vitaly
authors.initials: V
authors.lastname: Margulis
mesh_terms: D000293:Adolescent; D000328:Adult; D018572:Disease-Free Survival; D006801:Humans; D008297:Male; D011446:Prospective Studies; D012017:Referral and Consultation; D013736:Testicular Neoplasms / Q000175:diagnosis* / Q000473:pathology; D055815:Young Adult
keywords: germ-cell malignancy; oncologic outcomes; testicular cancer