Management of Active Surveillance-Eligible Prostate Cancer during Pretransplantation Workup of Patients with Kidney Failure: A Simulation Study

Abstract

Background and objectivesThe general rule that every active malignancy is an absolute contraindication for kidney transplantation is challenged by kidney failure patients diagnosed with active surveillance-eligible prostate cancer during pretransplantation workup. Interdisciplinary treatment teams therefore often face the challenge of balancing the benefits of early kidney transplantation and the risk of metastatic progression. Hence, we compared the quality-adjusted life expectancy of different management strategies in kidney failure patients diagnosed with active surveillance-eligible prostate cancer during pretransplantation workup.Design, setting, participants, & measurementsA discrete event simulation model was developed on the basis of a systematic literature search, clinical guidelines, and expert opinion. After model validation and calibration, we simulated four management strategies in a hypothetical cohort of 100,000 patients: Definitive treatment (surgery or radiation therapy) and listing after a waiting period of 2 years, definitive treatment and immediate listing, active surveillance and listing after a waiting period of 2 years, and active surveillance and immediate listing. Individual patient results (quality-adjusted life years; QALYs) were aggregated into strategy-specific means (± SEs).ResultsActive surveillance and immediate listing yielded the highest amount of quality-adjusted life expectancy (6.97 ± 0.01 QALYs) followed by definitive treatment and immediate listing (6.75 ± 0.01 QALYs). These two strategies involving immediate listing not only outperformed those incorporating a waiting period of 2 years (definitive treatment: 6.32 ± 0.01 QALYs; active surveillance: 6.59 ± 0.01 QALYs) but also yielded a higher proportion of successfully performed transplantations (72% and 74% versus 56% and 59%), with less time on hemodialysis on average (4.02 and 3.81 years versus 4.80 and 4.65 years).ConclusionsAmong kidney failure patients diagnosed with active surveillance-eligible prostate cancer during pretransplantation workup, the active surveillance and immediate listing strategy outperformed the alternative management strategies from a quality of life expectancy perspective, followed by definitive treatment and immediate listing.

Impact of newly diagnosed prostate cancer at time of evaluation for renal transplantation

“…There is no evidence that PCa, in low-risk situations, alters either the quality of life or life expectancy, even if untreated. 18,21,22 Along with previous studies showing that differing active listing after PCa diagnosis was associated with a decrease in overall survival and quality of life, 5,17,23,24 our data supports active surveillance and immediate listing as a favored strategy for RT candidates with low risk PCa. Cancer specific survival rate was very favorable in our study at 99.1% at 5 years of PCa diagnosis, and studies have shown that PCa treatment after RT surgery had satisfactory results, with little risk regarding transplant function and survival.…”

“…In their latest guidelines, the American Society of Transplantation recommends no wait time for patients with very low‐risk and low‐risk diseases, for which active surveillance is strongly recommended, as well as patients with low‐volume intermediate‐risk managed with active surveillance 16 . Our data may suggest that offering active surveillance concomitantly to immediate active listing may further facilitate access to RT at the time of PCa diagnosis in low‐grade patients, without impairing oncological outcome, as previously suggested in a simulation study 17 …”

“…16 Our data may suggest that offering active surveillance concomitantly to immediate active listing may further facilitate access to RT at the time of PCa diagnosis in low-grade patients, without impairing oncological outcome, as previously suggested in a simulation study. 17 Our data showed that, during the study period, patients who underwent radical prostatectomy and active surveillance protocols had a higher rate of access to active listing and RT surgery, compared to patients with up-front radiotherapy (Figure 1). Radical prostatectomy allows precise anatomopathological grading, and unequivocal assertation of therapeutic success when post-operative PSA is undetectable.…”

Treatment patterns and survival of low and intermediate‐risk prostate cancer in end‐stage kidney disease: A retrospective population cohort study

“…A simulation study of 10,000 hypothetical KT‐eligible candidates with low‐risk PCa concluded that quality‐adjusted life years and KT rates were highest for AS and immediate eligibility strategy for KT. 24 A recent expert opinion recommendation from the AST/ASTS for low‐risk PCa recommends AS and immediate approval for KT. 25 Since KT improves the overall mortality of dialysis patients, we support that consideration needs to be given to managing low‐risk PCa among dialysis patients by AS.…”

“…Based on this study's recommendations since all patients in the dialysis cohort in our study with low‐risk PCa carried a CCI of >2 (due to dialysis status) 23 and likely had a < GG2 PCa, they would have met criteria for WW. A simulation study of 10,000 hypothetical KT‐eligible candidates with low‐risk PCa concluded that quality‐adjusted life years and KT rates were highest for AS and immediate eligibility strategy for KT 24 . A recent expert opinion recommendation from the AST/ASTS for low‐risk PCa recommends AS and immediate approval for KT 25 .…”