Original article
National treatment trends among older patients with T1-localized renal cell carcinoma1

https://doi.org/10.1016/j.urolonc.2016.10.008Get rights and content

Abstract

Objective

To assess the national trends in treatment of localized renal tumors among older patients with limited life expectancy.

Materials and methods

Using the National Cancer Database, we identified older patients (≥70 y) diagnosed with T1 renal cell carcinoma from 2002 to 2011. Primary outcome was the initial treatment—partial nephrectomy (PN), radical nephrectomy, EM, and ablation. Multivariable logistic regression analysis stratified by tumor size (<2, 2–3.9, or 4–7 cm) and age groups (70–79 and ≥80 y) was used to identify covariates associated with different treatments.

Results

Among 41,518 older patients with T1 renal cell carcinoma renal tumors, most were treated with radical nephrectomy (59.0%) followed by PN (20.0%) and ablation (8.4%). Only 12.6% were managed by EM. Among older patients aged 70 to 79 years with renal tumors 2 to 3.9 cm, PN was used more frequently in 2008 to 2009 (odds ratio [OR] = 1.32; P = 0.001) and 2010 to 2011 (OR = 1.87; P<0.001) compared to 2002 to 2003 and at academic hospitals (OR = 1.91; P<0.001) compared to community hospitals. Similar trends were observed for patients aged 70 to 79 years with 4 to 7 cm tumors and for patients aged≥80 years across renal tumor sizes.

Conclusions

Among older patients with localized renal tumors and limited life expectancy, most are treated surgically with a growing use of PN. A smaller proportion of older patients are managed by EM in the United States.

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

References (27)

  • W.H. Chow et al.

    Rising incidence of renal cell cancer in the United States

    J Am Med Assoc

    (1999)
  • J.M. Hollingsworth et al.

    Rising incidence of small renal masses: a need to reassess treatment effect

    J Natl Cancer Inst

    (2006)
  • R.L. Siegel et al.

    Cancer statistics, 2015

    CA Cancer J Clin

    (2015)
  • Cited by (27)

    • Development and Validation of a Nomogram Predicting Intraoperative Adverse Events During Robot-assisted Partial Nephrectomy

      2023, European Urology Focus
      Citation 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

      2021, European Urology Open Science
      Citation Excerpt :

      Patients who are comorbid or elderly may, therefore, be particularly suitable for AS. This is reflected in the rising trend of AS in patients over 70 yr of age, with the rate of AS increasing from 9.8% in 2002 to 13.6% in 2011 [12]. Understanding the current utilization of AS for cT1aRMs or cT1RMs is difficult, with an analysis of large national datasets such as the National Cancer Database (NCDB) and the Surveillance, Epidemiology and End Results (SEER)-Medicare database reporting AS utilization from 2.7% to 30% [13–16].

    View all citing articles on Scopus
    1

    Dr. Simon P. Kim is supported by a career development award from the Conquer Cancer Foundation from the American Society of Clinical Oncology.

    View full text