Urologic Oncology: Seminars and Original Investigations
Original articleNational treatment trends among older patients with T1-localized renal cell carcinoma1
Introduction
Two population trends are occurring in the United States that would increase complexity of treatment decisions for small renal masses (SRMs). The incidence of SRMs has been gradually rising such that clinical T1 renal tumors represent most incident cases, which has been attributable to the growing use of imaging [1], [2]. Approximately 60,000 patients would face a diagnosis of renal cell carcinoma (RCC) making it the sixth most common cancer in the United States this year [3]. Against this backdrop, the U.S. population is growing older. The average life expectancies for both men and women have been steadily increasing such that a fifth of the U.S. population would be aged 65 years or older by 2030 [4]. As a result, the rising proportion of elderly patients with incidentally detected localized renal tumors with uncertain malignant potential represents a management challenge with significant health policy implications.
Clinical practice guidelines currently endorse partial nephrectomy (PN) for SRMs amenable to surgical resection [5], [6], [7]. Other possible treatment options for SRMs include radical nephrectomy (RN), ablation, or expectant management (EM). Although PN has become more technically feasible and safer with minimally invasive surgery, such as robotic PN, it still carries some morbidity and bleeding risks that may be poorly tolerated among older patients [8], [9]. With the changes in clinical practice guidelines and rapid dissemination of robotic surgery, the national rates of PN have been gradually rising in the United States [10]. However, EM has become an increasingly accepted disease management strategy for SRMs based on the growing number of studies suggesting the modest annual growth rates of the renal tumor and low risk of metastatic potential and cancer-related mortality, in particular among patients with a limited life expectancy [11], [12], [13] Yet, an important knowledge gap is the contemporary trends in the treatment of SRMs among older patients in the United States, as some older patients may be exposed to aggressive treatments and its associated morbidities without receiving a survival benefit. In this context, we assessed the contemporary national treatment trends of older patients (>70 y) diagnosed with SRMs.
Section snippets
Data source
We queried the National Cancer Database (NCDB), a joint project of the Commission on Cancer of the American College of Surgeons and the American Cancer Society, to examine surgical treatment in elderly patients with SRMs [14]. The NCDB is a national oncology dataset obtained from more than 1,500 hospitals that contains no patient- or physician-identifying information. Approximately 70% of newly diagnosed malignancies are captured in the NCDB.
Study population
We identified all adult patients aged≥70 with kidney
Results
From 2002 to 2011, we identified 41,518 patients diagnosed with RCC in the NCDB. As shown in Table 1, most patients were aged between 70 and 79 years (71.4%), white (77.3%), and relatively healthy with no Charlson comorbidities (63.0%). Most patients were treated in urban locations (80.8%) and at comprehensive community hospitals (55.3%), whereas only a third of patients were treated at academic hospitals (32.6%). During the study interval, most patients had a clear cell RCC histology (83.0%)
Discussion
Our study presents important information at a time when the patient population is growing older, and there is a rising incidence of SRMs in the United States, along with a growing trend in the use of surgical therapy, in particular, PN [10], [19]. Yet, it is essential to recognize that clinical practice guidelines do not identify specific patient characteristics where PN is most efficacious for improving outcomes other than tumor location and complexity. Against this backdrop, our study has
Conclusion
In summary, most patients who have advanced age and T1 renal tumors with localized RCC are receiving surgery with PN or RN from 2002 to 2011. Over time, there have been shifts toward increased use of PN and EM/active surveillance (AS), though the latter represents a small fraction of all older patients diagnosed with T1 RCC. Increased attention to all available treatment options and EM is needed to facilitate shared decision-making about the associated risks and benefits for older patients and
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2023, European Urology FocusCitation Excerpt :Decision curve analysis revealed a net clinical benefit of using the model at threshold probabilities >5% (Fig. 3). Utilization of PN for the management of localized SRMs has seen an upward trend [16,17]. PN involves finely orchestrated critical substeps such as hilar control, tumor delineation, resection, and renal reconstruction.
Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative
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Dr. Simon P. Kim is supported by a career development award from the Conquer Cancer Foundation from the American Society of Clinical Oncology.