Burden or relief: do second-opinion centers influence the quality of care delivered to patients with testicular germ cell cancer?

Abstract

Background: To improve the quality of care, the German Testicular Cancer Study Group (GTCSG) has been publishing a series of testicular germ cell cancer guidelines since 1996. These guidelines were updated in the 2008 publication, "European Consensus on Diagnosis and Treatment of Germ Cell Cancer." Several studies have shown that published guidelines have a limited effect on clinical practice. For this reason, the GTCSG made a further effort in 2006 to improve the quality of care by establishing a national second-opinion system for therapy planning for patients who underwent orchiectomy and staging evaluations.

Objective: The primary aim was to analyze the influence of the second-opinion system on guideline implementation with a view to improving the quality of care.

Design, setting, and participants: An Internet data exchange was established between the urologist seeking advice and the second-opinion centers. Second-opinion centers were 18 clinics that had contributed toward developing treatment guidelines.

Measurements: Data sets included the primary clinical, radiologic, and pathohistologic data; the planned therapy; the therapy recommended by the second-opinion center; and the follow-up.

Results and limitations: From February 2006 to September 2008, 642 second opinions were requested. The therapy planned by the urologist seeking advice differed from that recommended by the second-opinion center in 32.3% of the cases. The discrepancy was significantly higher for nonseminomas than for seminomas (p=0.045) and showed a tendency to increase with advancing tumor stage (p=0.067). In cases of discrepancy, the applied therapy coincided with the second opinion in 71.8% of the cases. A discrepant second opinion prevented overtreatment in 40.3% and undertreatment in 26.5%.

Conclusions: Approximately every sixth second opinion resulted in a relevant change in the scope of therapy. Published guidelines for germ cell cancer are applied only sporadically and should be supported by second-opinion systems.