Case Presentation: A 30 year old male presented to the emergency department one day after release from incarceration, seeking care for a testicular mass. He reported being evaluated six months prior, however had been unable to schedule a biopsy and oncology follow-up before incarceration. He reported an increasing size of the mass, with new and worsening abdominal pain radiating to the groin, chest pain, and shortness of breath, which were later attributed to retroperitoneal lymph nodes and multiple lung metastases. He underwent a right orchiectomy, which confirmed testicular choriocarcinoma, and was started on adjuvant chemotherapy (bleomycin sulfate, etoposide phosphate, and cisplatin). He had multiple admissions between subsequent chemotherapy cycles due to complications from fentanyl use, including a suicide attempt related to difficulty coping with his diagnosis.
Discussion: This is a case of metastatic testicular choriocarcinoma in a young patient that highlights how social determinants of health can directly impact healthcare outcomes. Population studies suggest that while the general incidence of cancer is lower among incarcerated individuals, it is disproportionately higher in the post-release population. This data suggests that cancer underdiagnosis and diagnostic delays are more common among incarcerated patients. As a result these patients are placed at risk for higher morbidity and mortality. Recent studies indicate that the risk of cancer mortality within five years is significantly higher for incarcerated (1.12-1.73) and recently released individuals (1.57-2.1), highlighting the impact of delayed diagnosis and treatment. While their status as incarcerated patients may appear unidimensional, literature has supported the complex dynamics at play that impair care. Key themes that emerge for them include limited access to healthcare prior to, during, and after incarceration, lack of continuity of care, insufficient health literacy, and limited social support.
Conclusions: This case underscores the critical need for healthcare providers and institutions to address the unique barriers faced by incarcerated and recently released patients to improve timely cancer diagnosis and treatment. Ensuring continuity of care and addressing mental health and substance use issues may improve cancer-related patient outcomes. While incorporating social determinants of health into medical education proves to be a useful tool to spread this understanding, it may not be sufficient alone. A promising development in improving care for these patients is the Centers for Medicare and Medicaid Services’ recent introduction of billing codes for addressing social determinants of health. While these codes do not specifically target incarcerated individuals, they may encourage health providers to capture and address barriers such as substance use, mental health, and healthcare access, ultimately improving care for this vulnerable population.