Demographic predictors of primary retroperitoneal lymph node dissection (P-RPLND) vs. primary chemotherapy (P-Ch) in the treatment of clinical stage IIA/B (CSIIA/B) non-seminomatous testicular germ cell tumors (NSGCTs).

594 Background: Traditional treatment for CSIIA/B NSGCTs has been primary cisplatin-based chemotherapy (P-Ch) or primary RPLND (P-RPLND). However, P-Ch may have long term sequela including ototoxicity, peripheral neuropathy, pulmonary fibrosis, decreased fertility, and secondary malignancies. Recent studies have reintroduced P-RPLND as an alternative to P-Ch to minimize long-term toxicity without negatively impacting oncologic outcomes. This study aims to characterize non-clinical factors influencing the decision between P-Ch and P-RPLND for patients with CSIIA/B NSGCT and the overall survival (OS) associated with these modalities. Methods: The National Cancer Database (NCDB) was queried to identify patients with CSIIA/B NSGCT diagnosed 2004-2021. Patients were classified as having received P-Ch or P-RPLND based on date fields. Demographic differences were determined using chi-squared analysis. Odds ratios were calculated using multivariate binomial logistic regression, and OS was assessed using multivariate Cox regression while controlling for age, clinical stage, comorbidities, income, and housing status. Results: 5,514 patients (mean age 30.3 years, 81.6% white, 73.5% privately insured) were included. A total of 4,017 (74.2%) patients received P-Ch while 1,163 (25.8%) underwent P-RPLND. Patients insured with Medicaid and those in the lowest education quartile were significantly less likely to undergo P-RPLND (OR: 0.76, 95% CI: 0.70-0.83, p = 0.007; OR: 0.77, 95% CI: 0.63-0.95, p = 0.02). Patients with higher disease stage (CSIIB vs. CSIIA) and LVI+ at orchiectomy were less likely to undergo P-RPLND (OR: 0.59, 95% CI: 0.52-0.67, p < 0.001; OR: 0.79 95% CI: 0.69-0.91, p = 0.002). Of the entire cohort, the P-Ch group had 235 deaths (5.9%) while 1,397 underwent P-RPLND with 57 deaths (4.0%). Conclusions: Patients with lower socioeconomic status (SES) such as Medicaid insurance and those with lower levels of education are significantly less likely to undergo P-RPLND for CSIIA/B NSGCTs. While P-RPLND remains an extremely effective treatment modality in select patients, those with lower SES disproportionately receive chemotherapy as initial treatment.