This interview in honor of Testicular Cancer Awareness Month features Dr. Andrew Winer, Chief of Urology at Kings County Hospital in New York. Dr. Winer discusses the ongoing research regarding new approaches for testicular cancer surgery, strategies to address disparities in health care access for underserved populations, and the importance of taking a multidisciplinary approach to achieve the best possible outcomes for patients with testicular cancer.
This interview has been conducted in partnership with the American Urological Association, a premier urologic association, providing invaluable support to the urologic community. Their mission is to promote the highest standards of urological clinical care through education, research, and the formulation of health care policy.
Oncology Data Advisor: Welcome to Oncology Data Advisor. Today I'm here with Dr. Andrew Winer, who is the Chief of Urology at Kings County Hospital in New York. Thank you so much for joining us, Dr. Winer.
Andrew Winer, MD, FACS: Good morning. My name's Andrew Winer. I'm the Chief of Urology at Kings County Hospital and a urologic oncologist. I'm an Associate Professor of Urology at SUNY Downstate and the program director for the residency. I take care of all things urologic oncology, and I'm excited to be here today to talk to you about testicular cancer.
Oncology Data Advisor: What is some of the ongoing research investigating new approaches for testicular cancer surgery?
Dr. Winer: The initial surgery for testicular cancer diagnosis and management is actually a fairly straightforward one. An orchiectomy can give you a tissue diagnosis, and it can also treat a number of testicular cancers. There's not a ton of new research surrounding orchiectomy, although there is some interest in a partial orchiectomy, and there's some promising data supporting the use of partial orchiectomy in selected cases. But the real research surrounds RPLND, or retroperitoneal lymph node dissection. This is a highly complex operation, and it is performed by skilled surgeons who are doing a number of them per year. The research surrounds the use of open versus minimally invasive approaches, such as robotic surgery.
Also, we're looking at the template. The retroperitoneal lymph nodes are on both sides and in the middle between the aorta and the inferior vena cava (IVC). There are some studies that have been going on for a while, actually, looking at bilateral templates versus modified templates. The jury's still out to some extent as to which is the preferred modality. Depending on individuals that you talk to and institutions that you discuss with, everybody will kind of give you a different answer right now, but there is active research in that realm.
One of the most interesting areas of research in testicular cancer surgery that's going on right now is a recent multi-institutional trial called the SEMS trial, looking at stage II seminoma and surgery and whether or not it's indicated there. The authors actually found that the oncologic benefit of surgery in stage II seminoma, in the cohort that they identified, was equivalent to non-seminomas. This was surprising because the dogma for a long time in seminoma was that it's not a surgical disease once it's beyond the testis, so in the retroperitoneum, it was really just radiation and chemotherapy. But now we're starting to buck that dogma and look at surgical options, particularly in the retroperitoneum, in stage II seminoma, so that's exciting.
Oncology Data Advisor: What is the role of robotic surgery in testicular cancer treatment?
Dr. Winer: We're talking about young men here, and it's a big, highly complex operation working around major blood vessels in the retroperitoneum and vital organs. The key—and I really want to emphasize this—is proper surgery, a proper lymph node dissection. Really, robotics is just a tool to allow a surgeon to do that operation. I think it's more important to discuss what that particular surgeon is more comfortable with in doing a thorough lymph node dissection.
With that said though, there are a lot of emerging studies that show feasibility and oncologic equivalence of doing robotic versus open. In training these days, our residents and our trainees and fellows are getting a lot more experience robotically and find that this approach is less cumbersome on the surgeon, less cumbersome on the patient, with faster recovery, shorter hospital stay, and less blood loss. But it is still very much up for debate as to whether or not it's ideal, and I think the ultimate discussion should be surrounding what that particular surgeon is more comfortable with in doing a thorough lymph node dissection.
Oncology Data Advisor: I know you've done extensive research in the area of health care disparities. How do these impact the treatment of patients with testicular cancer, and how can these be addressed?
Dr. Winer: It's something that's very near and dear to my heart, and something that we're passionate about in the area that I practice. There are a number of patients that are of lower socioeconomic status and underinsured. If you look at studies that have come out looking at the long-term outcomes comparing these two cohorts, there's a major difference in outcomes compared with those who have closer access and more readily available care. So I think we need to be paying more attention to this.
There was a nice study out of University of Texas (UT) Southwestern that looked at a model where you're considering a private academic institution and a safety net hospital, but the same group who are taking care of both. What you find is there is no difference in their outcomes when you have the same team managing those patients, so it's really about access. It's really about education, getting out into the community, raising awareness, and I think also dispelling some of the stigma that surrounds testicular cancer. Patients also delay their care because of shame or a feeling of infallibility, that they're invincible. I think we need to get more information out to the community and also create teams that manage these patients, both in safety net hospitals as well as in private academic centers
Oncology Data Advisor: To wrap up, do you have any advice for members of the oncology care team who are treating and managing patients with this disease?
Dr. Winer: A take-home message for me when treating testicular cancer patients is that this really should be a multidisciplinary approach. Too often in medicine we have silos that keep us separated and treating patients individually, whereas we have a lot of smart doctors taking care of patients, and ultimately they will benefit from our joint effort. A multidisciplinary team with regard to a highly complex type of cancer like testicular cancer will ultimately lead to benefit.
This was born out in studies, actually; another study looked at the multidisciplinary approach, and those patients did better when you compared them with national averages. This was a study out of Indiana University looking at a multidisciplinary approach versus just individual approaches, and they did better. So get your primary care doctor, your oncologist, your radiologist, your pathologist, and your urologist involved—all taking care of this patient as a team—and I think our patients will really, truly benefit from them.
Oncology Data Advisor: Thank you so much for sharing all this valuable information with us today.
About Dr. Winer
Andrew Winer, MD, FACS, is the Chief of Urology at Kings County Hospital Center and an Associate Professor in the Department of Urology at the State University of New York (SUNY) Downstate Health Sciences University. He is also the Director of Robotic Surgery at Kings County Hospital Center and the Associate Program Director for the Urology Residency at SUNY Downstate. Dr. Winer specializes in the treatment of urologic malignancies, and his research focuses on investigating novel approaches for urologic surgery and improving health care access for underrepresented populations.
For More Information
Daneshmand S, Cary C, Masterson T, et al (2021). SEMS trial: result of a prospective, multi-institutional phase II clinical trial of surgery in early metastatic seminoma. J Clin Oncol (ASCO Genitourinary Cancers Symposium Abstracts), 39(suppl_6). Abstract 375. DOI:10.1200/JCO.2021.39.6_suppl.375
Patel A, Howard JM, Chertack N, et al (2021). Disparities in pre-orchiectomy sperm cryopreservation among testicular cancer patients at a public safety net hospital and a private tertiary care center. Urology, S0090-4295(21)007241-4. DOI:10.1016/j.urology.2021.05.097
Albany C, Adra N, Snavely AC, et al (2018). Multidisciplinary clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors. Ann Oncol, 29(2):341-346. DOI:10.1093/annonc.mdx731
Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of Oncology Data Advisor.