On thin ice: barriers to adoption of surveillance for patients with stage I testicular seminoma. Survey of US radiation oncologists

ABSTRACT Purpose: Most men with stage I testicular seminoma are cured with surgery alone, which is a preferred strategy per national guidelines. The current pattern of practice among US radiation oncologists (ROs) is unknown. Materials and Methods: We surveyed practicing US ROs via an online questionnaire. Respondent's characteristics, self-rated knowledge, perceived patient compliance rates with observation were analyzed for association with treatment recommendations. Results: We received 353 responses from ROs, of whom 23% considered themselves experts. A vast majority (84%) recommend observation as a default strategy, however this rate drops to 3% if the patient is believed to be noncompliant. 33% of respondents believe that survival is jeopardized in case of disease recurrence, and among these respondents only 5% support observation. 22% of respondents over-estimate the likelihood of noncompliance with observation to be in the 50-80% range. Responders with a higher perceived noncompliance rate are more likely to recommend adjuvant therapy (Fisher's exact p<0.01). Only 7% of respondents recommend observation for stage IS seminoma and 45% administer adjuvant RT in patients with elevated pre-orchiectomy alpha-fetal protein levels. Conclusions: Many US ROs over-estimate the likelihood that stage I testicular seminoma patients will be noncompliant with surveillance and incorrectly believe that overall survival is jeopardized if disease recurs on surveillance. Observation is quickly dismissed for patients who are not deemed to be compliant with observation, and is generally not accepted for patients with stage IS disease. There is clearly an opportunity for improved physician education on evidence-based management of stage I testicular seminoma.

**摘要**
研究目的：Ⅰ期睾丸精原细胞瘤患者多数仅通过手术即可获得治愈，这也是各国临床指南推荐的首选治疗策略。目前美国放射肿瘤学家（radiation oncologists，ROs）的临床实践模式尚不明确。
材料与方法：本研究通过在线问卷对在职美国放射肿瘤学家（ROs）开展调研，分析受访者的基本特征、自我评估的专业知识水平、对患者接受随访观察依从性的主观评估结果，及其与治疗推荐方案之间的相关性。
研究结果：本研究共回收有效问卷353份，其中23%的受访者自认为是该领域专家。绝大多数（84%）的受访者将随访观察作为默认治疗策略，但当认为患者依从性不佳时，这一比例骤降至3%。33%的受访者认为，若疾病复发将危及患者生存，在该群体中仅5%仍支持采用随访观察方案。22%的受访者高估了患者随访观察的不依从概率，认为该比例处于50%~80%区间。主观评估患者不依从率越高的受访者，越倾向于推荐辅助治疗（费希尔精确检验p<0.01）。仅7%的受访者建议对ⅠS期睾丸精原细胞瘤患者采用随访观察，45%的受访者会在睾丸切除术前甲胎蛋白（alpha-fetal protein）水平升高的患者中实施辅助放疗（radiation therapy，RT）。
研究结论：多数美国放射肿瘤学家（ROs）高估了Ⅰ期睾丸精原细胞瘤患者对随访观察的不依从概率，且错误认为若随访期间疾病复发会危及患者总生存。对于被认为依从性不佳的患者，随访观察方案会被迅速否决；而ⅠS期睾丸精原细胞瘤患者通常也不会被推荐采用随访观察。当前临床实践中仍存在显著改进空间，需加强医师关于Ⅰ期睾丸精原细胞瘤循证管理的教育培训。