Guideline recommendations versus real-world management in early-stage testicular cancer: a multicenter survey of contemporary practice.

Background: Early-stage testicular cancer is highly curable; however, overtreatment may result in substantial long-term toxicity. Current guidelines aim to balance relapse risk and treatment-related morbidity, yet real-world adherence remains unclear. Objectives: To assess real-world management of clinical stage (cS) I and cSIIA testicular cancer in specialized centers and to evaluate the extent to which guideline recommendations are implemented or deviated from to avoid overtreatment. Design: Multicenter questionnaire-based cross-sectional study. Methods: A structured 17-item survey was distributed to 59 urological, medical oncology, and radiation oncology experts from the German Testicular Cancer Study Group (GTCSG) and university hospitals in Germany and Switzerland. Survey topics included staging, repeated imaging, and treatment strategies for seminoma and non-seminomatous germ cell tumors (NSGCT) in cSI and cSIIA with negative serum tumor markers (S0). Statistical analyses were performed using descriptive statistics and chi-square testing. Results: Fifty-three questionnaires (89.8%) were evaluable. Although current guidelines recommend active surveillance as the preferred management for cSI seminoma, irrespective of risk factors, 52.9% of institutions administered adjuvant therapy in patients with risk factors. For cSI NSGCT, only 11.5% always applied active surveillance, independent of risk factors, despite guideline-supported recommendations for this approach. In cSIIA seminoma, 43.4% routinely repeated staging imaging prior to treatment initiation, although this strategy is not uniformly guideline endorsed. Conversely, only 31.4% consistently repeated imaging in cSIIA NSGCT, despite explicit guideline recommendations supporting repeat imaging before treatment. Treatment decisions after repeat imaging were predominantly based on lymph node (LN) progression (⩾20% increase). Additional biomarkers such as microRNA-371 were used only in a minority of centers. Conclusion: Substantial discrepancies exist between guideline recommendations and real-world practice in early-stage testicular cancer management. While guideline adherence is essential to prevent overtreatment, repeated imaging in cSIIA seminoma may represent a reasonable de-escalation strategy and should be considered for consistent future guideline integration.