Ten thousand attentive hours, rapid learning, dissemination of knowledge and the future of experience-based care in germ-cell tumors

Ten thousand attentive hours, rapid learning, dissemination of knowledge and the future of... In the short book by Geoff Colvin, ‘Talent is Overrated’, the author describes great performers being forged, not by God-given talent, but by having invested significant time in practice of the craft you seek to master [1]. Crucially, however, that practice cannot be mindless repetition, but must be infused with patience, presence and focus to consistently improve performance. It is only then that ordinarily capable people can achieve consistent great performance. Similarly Malcolm Gladwell in his book ‘Outliers’ popularized psychologist K. Anders Ericsson’s concept of the 10 000-h rule to becoming an expert in your field [2]. While some psychologists have challenged this notion with regard to abstract fields, few argue that practice indeed makes a difference in ‘structured’ fields such as games, music and sports. In the article in this issue of Annals of Oncology by Albany et al., the authors report comparative outcomes for patients with metastatic germ-cell tumors in the SEER US cancer registry, and demonstrate significantly improved outcomes for patients initially managed by the Indiana University Multidisciplinary Germ Cell Tumor Clinic relative to the national registry [3]. The conclusion that superior outcomes are obtained in high volume centers where coordinated multidisciplinary care is available is intuitive and there have been several recent articles supporting the directionality of these data specifying multidisciplinary experience as a key aspect in achieving best care for patients with not only germ-cell tumors, but also other genitourinary malignancies such as bladder cancer [3–7]. We believe that the conclusions of the authors are sound and timely. As a frame of reference for the modern era in germ-cell tumor management, it is important to note how the few current expert centers developed and subsequently achieved the golden 10 000 h. Most often, it has begun as a duet including an academic urologic surgeon and what was then a new specialty, an academic medical oncologist [8]. This nidus, often serendipitously formed, allowed for focused exchange of ideas, different perspectives, expansion of the multidisciplinary team and most importantly, attracted more patients that promoted research and further investigation and propagation of knowledge. As time moved forward, a virtuous snowballing effect occurred with more repetition, learning from mistakes, and a growing understanding of the disease, the treatments and the consequences of treatments for these unique patients. The accumulation of experience allows for understanding subtleties and nuance and being able to effectively streamline safe and effective treatment of the most common patients and customize approaches for physiologic or social outliers. Another inception was the early establishment of collaborative groups of physicians carefully sharing experience, developing guidelines and prospectively evaluating treatment results in a perpetual cycle [9]. This is all well and good if you happen to develop your testicular cancer while living in Indianapolis or New York City, Los Angeles, Vancouver, BC, Toronto, Paris, Hamburg, London, Scandinavia or a handful of other centers in North America and Europe. It is fine if your situation is such that you, as a patient, become aware of where deeper expertise exists, are referred initially to one of these centers AND you have the means to travel and stay near one of the centers for treatment. Certainly, in the United States and most other countries, it is only a small fraction of all patients who are seen in these few expert centers and, thus, the advantage of center experience is only marshalled for the benefit of a few patients. We know that non-guideline directed care of patients with testicular cancer is common, and leads to delayed definitive therapy, unnecessary morbidity and higher rates of relapse [10]. Knowing now that the magnitude of the benefit of experience probably exceeds the impact of discovery of a new molecular pathway in germ-cell tumors, the precise mechanism of cisplatin-resistance or the development of a more effective systemic therapy, the essential question becomes how we best leverage this spotty and hard-won experience and weaponize the knowledge accrued at high volume expert centers and collaborative groups to advantage all patients regardless of means or geography. The inadequate answer perpetrated in an era before facile electronic information exchange was to recommend referral of patients to these few expert centers. This was impractical, largely unsuccessful and primarily benefitted patients who could afford displacement from their home towns. Albany et al. conclude their otherwise spot-on manuscript stating that we should consider ‘reconstructing the health care delivery system’ to ‘enhance value and improve outcomes’. This is perhaps tepid from the most experienced and productive germ-cell program in the world. We all recognize the largely surmountable barriers to broadcasting individualized decision making and appropriate triage. We all are quite aware of very effective regional and even national collaborative programs have been organized to produce comprehensive, low cost results for populations comparable to the best single institutional results with the long standing Scandinavian collaborative, SWENOTECA, continuing to stand as the exemplar effort in the world today (www.swenoteca.org). It is time that the germ-cell tumor community put a stake in the ground behind the vision that all patients should have access to the exceptional experience, knowledge and results available at the few elite centers in the world. We can and should identify and overcome business barriers and resistance related to local autonomy desires by providers. Expert centers need to continue to develop cordial, respectful and open relationships with providers and patients everywhere. Knowing what we now know and with the availability of near zero cost transfer of information and knowledge, we can no longer afford to leave the very powerful asset of vast experience on the sideline in routine care of patients with germ-cell tumors or other uncommon curable diseases. Funding This editorial was supported in part by the National Cancer Institute of the National Institutes of Health under Award Number U10 CA180888. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Disclosure The authors have declared no conflicts of interest. References 1 Colvin G. Talent is overrated: what really separates world class performers from everyone else? ISPN 978-1591842248 ( 2008). Colvin publisher, The Penguin Group. 2 Gladwell M. Outliers: the story of success Int’led, ISBN 978-0-316-03669-6 ( 2008). Gladwell Publisher, Little, Brown and Company. 3 Albany C, Adra N, Snavely AC et al.   Multidisciplinary Clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors. Ann Oncol 2018; 29( 2): 341– 346. 4 Tandstad T, Kollmannsberger C, Roth BJ et al.   Practice makes perfect: the rest of the story in testicular cancer as a model curable neoplasm. JCO  2017; 35( 31): 3525– 3528. Google Scholar CrossRef Search ADS   5 Feuer EJ, Sheinfeld J, Bosl GJ. Does size matter? Association between number of patients treated and patient outcome in metastatic testicular cancer. J Natl Cancer Inst  1999; 91( 10): 816– 818. Google Scholar CrossRef Search ADS PubMed  6 Jeldres C, Pham K, Daneshmand S et al.   Association of higher institutional volume with improved overall survival in clinical stage III testicular cancer: results from the National Cancer Data Base (1998–2011). J Clin Oncol  2014; 32( 5 Suppl) (Abstr 4519). 7 Udovicich C, Perera M, Huq M et al.   Hospital volume and perioperative outcomes for radical cystectomy: a population study. BJU Int  2017; 119( Suppl 5): 26– 32. Google Scholar CrossRef Search ADS PubMed  8 Einhorn LH, Donohue J. Cis-diamminodichloroplatinum, vinblastine and bleomycin in disseminated testicular cancer. Ann Intern Med  1977; 87( 3): 293– 298. Google Scholar CrossRef Search ADS PubMed  9 Tandstad T, Ståhl O, Håkansson U et al.   The SWENOTECA group—a good example of continuous binational and multidisciplinary collaboration for patients with testicular cancer in Sweden and Norway. Scand J Urol  2016; 50( 1): 9– 13. Google Scholar CrossRef Search ADS PubMed  10 Wymer KM, Pearce SM, Harris KT et al.   Adherence to National Comprehensive Cancer Network® guidelines for testicular cancer. J Urol  2017; 197( 3 Pt 1): 684– 689. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2017. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For Permissions, please email: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Annals of Oncology Oxford University Press

Ten thousand attentive hours, rapid learning, dissemination of knowledge and the future of experience-based care in germ-cell tumors

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Oxford University Press
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© The Author(s) 2017. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.
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0923-7534
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1569-8041
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10.1093/annonc/mdx779
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Abstract

In the short book by Geoff Colvin, ‘Talent is Overrated’, the author describes great performers being forged, not by God-given talent, but by having invested significant time in practice of the craft you seek to master [1]. Crucially, however, that practice cannot be mindless repetition, but must be infused with patience, presence and focus to consistently improve performance. It is only then that ordinarily capable people can achieve consistent great performance. Similarly Malcolm Gladwell in his book ‘Outliers’ popularized psychologist K. Anders Ericsson’s concept of the 10 000-h rule to becoming an expert in your field [2]. While some psychologists have challenged this notion with regard to abstract fields, few argue that practice indeed makes a difference in ‘structured’ fields such as games, music and sports. In the article in this issue of Annals of Oncology by Albany et al., the authors report comparative outcomes for patients with metastatic germ-cell tumors in the SEER US cancer registry, and demonstrate significantly improved outcomes for patients initially managed by the Indiana University Multidisciplinary Germ Cell Tumor Clinic relative to the national registry [3]. The conclusion that superior outcomes are obtained in high volume centers where coordinated multidisciplinary care is available is intuitive and there have been several recent articles supporting the directionality of these data specifying multidisciplinary experience as a key aspect in achieving best care for patients with not only germ-cell tumors, but also other genitourinary malignancies such as bladder cancer [3–7]. We believe that the conclusions of the authors are sound and timely. As a frame of reference for the modern era in germ-cell tumor management, it is important to note how the few current expert centers developed and subsequently achieved the golden 10 000 h. Most often, it has begun as a duet including an academic urologic surgeon and what was then a new specialty, an academic medical oncologist [8]. This nidus, often serendipitously formed, allowed for focused exchange of ideas, different perspectives, expansion of the multidisciplinary team and most importantly, attracted more patients that promoted research and further investigation and propagation of knowledge. As time moved forward, a virtuous snowballing effect occurred with more repetition, learning from mistakes, and a growing understanding of the disease, the treatments and the consequences of treatments for these unique patients. The accumulation of experience allows for understanding subtleties and nuance and being able to effectively streamline safe and effective treatment of the most common patients and customize approaches for physiologic or social outliers. Another inception was the early establishment of collaborative groups of physicians carefully sharing experience, developing guidelines and prospectively evaluating treatment results in a perpetual cycle [9]. This is all well and good if you happen to develop your testicular cancer while living in Indianapolis or New York City, Los Angeles, Vancouver, BC, Toronto, Paris, Hamburg, London, Scandinavia or a handful of other centers in North America and Europe. It is fine if your situation is such that you, as a patient, become aware of where deeper expertise exists, are referred initially to one of these centers AND you have the means to travel and stay near one of the centers for treatment. Certainly, in the United States and most other countries, it is only a small fraction of all patients who are seen in these few expert centers and, thus, the advantage of center experience is only marshalled for the benefit of a few patients. We know that non-guideline directed care of patients with testicular cancer is common, and leads to delayed definitive therapy, unnecessary morbidity and higher rates of relapse [10]. Knowing now that the magnitude of the benefit of experience probably exceeds the impact of discovery of a new molecular pathway in germ-cell tumors, the precise mechanism of cisplatin-resistance or the development of a more effective systemic therapy, the essential question becomes how we best leverage this spotty and hard-won experience and weaponize the knowledge accrued at high volume expert centers and collaborative groups to advantage all patients regardless of means or geography. The inadequate answer perpetrated in an era before facile electronic information exchange was to recommend referral of patients to these few expert centers. This was impractical, largely unsuccessful and primarily benefitted patients who could afford displacement from their home towns. Albany et al. conclude their otherwise spot-on manuscript stating that we should consider ‘reconstructing the health care delivery system’ to ‘enhance value and improve outcomes’. This is perhaps tepid from the most experienced and productive germ-cell program in the world. We all recognize the largely surmountable barriers to broadcasting individualized decision making and appropriate triage. We all are quite aware of very effective regional and even national collaborative programs have been organized to produce comprehensive, low cost results for populations comparable to the best single institutional results with the long standing Scandinavian collaborative, SWENOTECA, continuing to stand as the exemplar effort in the world today (www.swenoteca.org). It is time that the germ-cell tumor community put a stake in the ground behind the vision that all patients should have access to the exceptional experience, knowledge and results available at the few elite centers in the world. We can and should identify and overcome business barriers and resistance related to local autonomy desires by providers. Expert centers need to continue to develop cordial, respectful and open relationships with providers and patients everywhere. Knowing what we now know and with the availability of near zero cost transfer of information and knowledge, we can no longer afford to leave the very powerful asset of vast experience on the sideline in routine care of patients with germ-cell tumors or other uncommon curable diseases. Funding This editorial was supported in part by the National Cancer Institute of the National Institutes of Health under Award Number U10 CA180888. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Disclosure The authors have declared no conflicts of interest. References 1 Colvin G. Talent is overrated: what really separates world class performers from everyone else? ISPN 978-1591842248 ( 2008). Colvin publisher, The Penguin Group. 2 Gladwell M. Outliers: the story of success Int’led, ISBN 978-0-316-03669-6 ( 2008). Gladwell Publisher, Little, Brown and Company. 3 Albany C, Adra N, Snavely AC et al.   Multidisciplinary Clinic approach improves overall survival outcomes of patients with metastatic germ-cell tumors. Ann Oncol 2018; 29( 2): 341– 346. 4 Tandstad T, Kollmannsberger C, Roth BJ et al.   Practice makes perfect: the rest of the story in testicular cancer as a model curable neoplasm. JCO  2017; 35( 31): 3525– 3528. Google Scholar CrossRef Search ADS   5 Feuer EJ, Sheinfeld J, Bosl GJ. Does size matter? Association between number of patients treated and patient outcome in metastatic testicular cancer. J Natl Cancer Inst  1999; 91( 10): 816– 818. Google Scholar CrossRef Search ADS PubMed  6 Jeldres C, Pham K, Daneshmand S et al.   Association of higher institutional volume with improved overall survival in clinical stage III testicular cancer: results from the National Cancer Data Base (1998–2011). J Clin Oncol  2014; 32( 5 Suppl) (Abstr 4519). 7 Udovicich C, Perera M, Huq M et al.   Hospital volume and perioperative outcomes for radical cystectomy: a population study. BJU Int  2017; 119( Suppl 5): 26– 32. Google Scholar CrossRef Search ADS PubMed  8 Einhorn LH, Donohue J. Cis-diamminodichloroplatinum, vinblastine and bleomycin in disseminated testicular cancer. Ann Intern Med  1977; 87( 3): 293– 298. Google Scholar CrossRef Search ADS PubMed  9 Tandstad T, Ståhl O, Håkansson U et al.   The SWENOTECA group—a good example of continuous binational and multidisciplinary collaboration for patients with testicular cancer in Sweden and Norway. Scand J Urol  2016; 50( 1): 9– 13. Google Scholar CrossRef Search ADS PubMed  10 Wymer KM, Pearce SM, Harris KT et al.   Adherence to National Comprehensive Cancer Network® guidelines for testicular cancer. J Urol  2017; 197( 3 Pt 1): 684– 689. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2017. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Journal

Annals of OncologyOxford University Press

Published: Feb 1, 2018

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