Cytoreductive nephrectomy for metastatic renal cell carcinoma: inequities in access exist despite improved survival

Abstract

The use of cytoreductive nephrectomy (CRN) in the targeted therapy era is still debated. We aimed to determine factors associated with reduced use of CRN and determine the effect of CRN on overall survival in patients with metastatic renal cell carcinoma (RCC). All advanced RCC diagnosed between 2001 and 2009 in New South Wales, Australia, were identified from the Central Cancer Registry. Records of treatment and death were electronically linked. Follow‐up was to the end of 2011. Multivariable logistic regression analysis was used to determine factors associated with the receipt of CRN. Cox proportional hazards model was used to determine factors associated with survival. A total of 1062 patients were identified with metastatic RCC of whom 289 (27%) received CRN. There was no difference in the use of CRN over the time period of the study. Females (OR 0.68 (95% CI: 0.48–0.96)), unmarried individuals (OR 0.68 (95% CI: 0.48–0.96)), treatment in a nonteaching hospital (OR 0.26 (95% CI: 0.18–0.36)) and individuals without private insurance (OR 0.29 (95% CI: 0.20–0.41)) all had reduced likelihood of receiving CRN. On multivariable analysis, not receiving CRN resulted in a 90% increase in death (HR 1.90 (95% CI: 1.61–2.25)). In addition, increasing age (P < 0.001), increasing Charlson comorbidity status (P = 0.002) and female gender also had a significant independent association with death. Despite a strong association with improved survival, individuals who are elderly, female, have treatment in a nonteaching facility or have no private insurance have a reduced likelihood of receiving CRN.

New prognostic model for synchronous metastatic renal cell carcinoma

“…Another randomized study, the SURTIME trial, showed that deferred nephrectomy after three cycles of sunitinib had relatively longer OS than immediate nephrectomy (32.4 vs 15.0 months), because more patients received sunitinib in the deferred nephrectomy group 17 . Furthermore, a number of retrospective studies showed the benefit of cytoreductive nephrectomy, including the present study 12,13,15,18–21 . Thus, cytoreductive nephrectomy is still expected to prolong survival, especially in patients with systemic therapy and long survival expectancy, so that the appropriate patient selection for nephrectomy is warranted.…”

Sex and Gender Differences in Kidney Cancer: Clinical and Experimental Evidence

“…Rampersaud et al, reported that females <59-year-old presented a better overall survival in comparison to males, suggesting a role for the hormones in RCC development [160]. Surprisingly, in metastatic RCC patients, female sex had a significant independent association with death (HR 1.19) [137]. Mancini et al, reported that disease recurrence seems not to be different among males and females, with the latter showing a more favorable prognosis after recurrence [105].…”

“…Such sex disparity seems to be particularly evident among African-American females [136]. Similarly, in the setting of metastatic RCC, Patel et al, found that females were less likely to undergo a cytoreductive nephrectomy as compared to their male counterparts [137]. In a population-based cohort study using data from the National Cancer Database, females with localized renal masses were treated more aggressively than males, with consequent significantly higher risks of overtreatment [138].…”

The current treatment patterns of metastatic renal cell carcinoma: A national cancer database review, 2004–2015

“…18 This phenomenon is not limited to the USA, as a population-based study in New South Wales noted a 91% decreased likelihood of undergoing CN if a patient was not privately insured. 19 Race may also play a role in treatment selection and access to care, as evidenced by a previous NCDB analysis identifying African American race as an independent risk factor for decreased survival, even in the targeted therapy era. 7 Our analysis elucidates this relationship further, and identifies several racial and socioeconomic risk factors associated with a patient receiving NT.…”