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Reply to So, now what?: Reflections on socioeconomic factors, testicular cancer, and health care accessibility

We thank the editorial board for the opportunity to respond to Rovito et al and their insightful comments on our article. Testis cancer is a highly curable disease. As highlighted in their comments and emphasized in the literature, it is no longer a question of ability to treat but is instead a question of how best to access treatment. As noted by Rovito et al, minority males are more likely to be limited in their access to care and health insurance and to be less aware of the disease and how best to seek treatment. This undoubtedly contributes to the higher stage at presentation observed in our study. Advanced testis cancer remains survivable and treatable, but delays are costly and risky for the patient. Unfortunately, many of these disadvantages remain out of the control of treating clinicians, and we are left to play catch-up. We consider ourselves fortunate to treat patients at a location where 2 disparate populations have access to our multidisciplinary model. We fully agree that the issue currently at hand is expanding this microcosm to a national level. The groundwork for a regional or national testis cancer care system exists in the form of cancer centers of excellence acting as referral centers for patients with testis cancer. However, it is not enough merely to be present; accessibility and action are required. Countless patient barriers exist (mainly distance and cost). To improve and streamline this system will require taking multidisciplinary care to the next level by incorporating social services, economic support, and political efforts. This begins with expanded coverage for disadvantaged populations, which has been proven time and again to reduce care delays. Young men are less likely to use office-based health care and primary care services. This is compounded in those who lack medical coverage, likely because of a hesitancy to pay increased costs.2 In the setting of testis cancer, Weiner et al demonstrated that increased access to health insurance through Medicaid expansion led to reduced delays in chemotherapy and radiotherapy. Unfortunately, there is reason to believe that even a more established safety net system similar to those systems used in other countries may not be a singular solution. The US Preventive Services Task Force has given screening for testicular cancer a grade D recommendation, so early detection of the disease relies on patient awareness and an established relationship with primary care. Adolescent males are less likely than females to discuss sexual health with primary care providers, and this represents a missed opportunity to increase early detection. Beyond acting as advocates for increasing access to care, urologists and medical oncologists can ensure that patients receive appropriate specialized care by remaining accessible to those clinicians most likely to encounter the disease: pediatricians, primary care physicians, and those working in urgent and emergent care. We agree with Rovito et al that all facilities treating testis cancer should achieve outcomes comparable to those of the International Germ Cell Cancer Collaborative Group or offer their patients access to facilities that do. Until such time that an organized model exists, we can work to emulate the benefits of such a system by publishing outcomes, educating our colleagues, and maintaining close relationships with other health care points of entry within our region. It is necessary to note that in the midst of the coronavirus pandemic, one of the few positives to arise has been the rapid implementation of telemedicine. This development has increased patient access to urologic care and provides the ability for physicians and other providers to collaborate from a distance. A small step in the right direction to defray patient costs and improve treatment adherence, it may serve as a tool for establishing large catchment networks for rare disease. We look forward to a future of truly accessible care for all and believe that this will lead to increasingly equitable patient outcomes.