尽管具有很高的可固化性,与在专业转诊中心接受治疗的患者相比,美国普通人群中转移性生殖细胞肿瘤(GCT)患者的结局持续较差.我们描述了一线化疗后复发的转移性GCT患者的指南不一致管理,并比较了最初在社区实践中接受治疗的患者与学术转诊中心。
2005年至2018年53例复发性GCT患者的回顾性分析。根据国家综合癌症网络指南评估一线GCT管理。指导方针不和谐管理,不和谐的预测因素,并评估了与结局的关联.
在53例复发性GCT患者中,34%的人在一线设置中接受了指南不一致的护理。指南不一致护理在最初在社区实践中接受治疗的患者中更为普遍(12/30,40%)最初在学术中心接受治疗的人(3/22,14%),尽管在多变量逻辑回归中,差异无统计学意义(比值比:4.07,P=0.08).大多数接受指南不一致护理的社区患者治疗不足(10/12,83%)。指南不一致的护理有3个主要原因:(1)化疗后未能切除残留肿块(27%,4/15),(2)化疗相关不良事件管理不善(27%,4/15),和(3)在诊断时分期,导致化疗方案强度不足(13%,2/15)和/或不适当地接受转移性疾病的原发性手术切除(20%,3/15)。
在最初在社区环境中接受治疗的患者中,有近一半的患者后来发展为复发性GCT。对于所有一线转移性GCT患者和所有化疗后残留疾病的患者,应考虑转诊至专业中心以寻求第二意见。应该开发更有效的方法来促进美国专家中心的第二意见。
Despite high curability, patients with metastatic germ cell tumors (GCT) in the United States general population persistently face inferior outcomes compared with those treated in specialty referral centers. We characterized
guideline discordant management in patients with metastatic GCT who experienced relapse after first-line chemotherapy and compared those who were initially treated in community practices vs. academic referral centers.
Retrospective analysis of 53 patients with relapsed GCT between 2005 and 2018. First-line GCT management was assessed against the National Comprehensive Cancer Network
guidelines. Guideline discordant management, predictors of discordance, and associations with outcomes were assessed.
Of 53 patients with relapsed GCT, 34% received
guideline discordant care in the first-line setting.
Guideline discordant care was more prevalent in patients initially treated in community practices (12/30, 40%) vs. those initially treated in academic centers (3/22, 14%), though in multivariate logistic regression, this difference was not statistically significant (odds ratio: 4.07, P = 0.08). Most patients in community settings who received
guideline discordant care were undertreated (10/12, 83%). There were 3 major reasons for guideline discordant care: (1) failure to resect residual masses after chemotherapy (27%, 4/15), (2) mismanagement of chemotherapy-related adverse events (27%, 4/15), and (3) under staging at diagnosis, resulting either insufficient chemotherapy regimen intensity (13%, 2/15) and/or inappropriately receiving primary surgical resection for metastatic disease (20%, 3/15).
Under treatment was identified in nearly half of patients initially treated in a community setting who later developed relapsed GCT. Referral to specialized centers for a second opinion should be considered for all metastatic GCT patients in the first-line setting and all patients with post-chemotherapy residual disease. More effective methods should be developed to facilitate second opinions from expert centers in the United States.