title: Impact of Urologist Density and County Rurality on the Practice of Retroperitoneal Lymph Node Dissection and Cancer-Specific Death in Patients with Nonseminomatous Germ Cell Tumors.
abstract: OBJECTIVE
  To investigate the impact of rural status and urologist density on the practice of retroperitoneal lymph node dissection (RPLND) and cancer-specific death (CSD) in patients with nonseminomatous germ cell tumor (NSGCT).
  
  
  METHODS
  Urologist density was determined from 2014 to 2015 Area Health Resource File data, and rural residence was determined using the 2003 Rural-Urban Continuum Codes. All cases of NSGCT within Surveillance, Epidemiology and End Results (SEER) 18 with known county code were used for analysis (n = 9473). Fisher's exact test, t-tests, and Cox proportional hazard analysis were used to examine the association between variables of interest and study endpoints.
  
  
  RESULTS
  Overall, 26.7% of cases lived in a county with less than the mean urologist density, 6.23% lived in counties with no urologists, 9.0% lived in a rural county, and 23.1% (n = 2208) had RPLND performed. RPLND was performed more in cases who lived in a county with a urologist and more in cases with urban residence (p < 0.05). The mean number of lymph nodes examined was lower in patients who lived in rural counties and counties with fewer urologists (p < 0.05). There was no difference in the number of positive nodes dependent upon either urologist density categorization or rurality (p > 0.05). Rurality and low urologist density were not associated with a higher risk of CSD related to NSGCT.
  
  
  CONCLUSIONS
  Patient's residence and access to urologists affect their surgical NSGCT treatment, and efforts aimed at improving access to high-quality RPLND may be indicated.
authors.affiliation: 1 Southern Illinois University School of Medicine , Springfield, Illinois.
authors.forename: Joseph
authors.initials: J
authors.lastname: Clemons
authors.affiliation: 1 Southern Illinois University School of Medicine , Springfield, Illinois.
authors.forename: Whitney E
authors.initials: WE
authors.lastname: Zahnd
authors.affiliation: 1 Southern Illinois University School of Medicine , Springfield, Illinois.
authors.forename: Max
authors.initials: M
authors.lastname: Nutt
authors.affiliation: 2 Division of Urology, Department of Surgery, Southern Illinois University School of Medicine , Springfield, Illinois.
authors.forename: Dan
authors.initials: D
authors.lastname: Sadowski
authors.affiliation: 2 Division of Urology, Department of Surgery, Southern Illinois University School of Medicine , Springfield, Illinois.
authors.forename: Danuta
authors.initials: D
authors.lastname: Dynda
authors.affiliation: 2 Division of Urology, Department of Surgery, Southern Illinois University School of Medicine , Springfield, Illinois.
authors.forename: Shaheen
authors.initials: S
authors.lastname: Alanee
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D054625:Healthcare Disparities; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008297:Male; D009373:Neoplasms, Germ Cell and Embryonal / Q000453:epidemiology* / Q000473:pathology; D013736:Testicular Neoplasms / Q000453:epidemiology* / Q000473:pathology; D055815:Young Adult
keywords: disparities; epidemiology; socioeconomic status (Ses); testicular cancer; treatment