Regional differences in practice patterns and associated outcomes for upper tract urothelial carcinoma in Canada

Abstract

Introduction: We delineated Canadian regional differences in practice patterns in the management of upper tract urothelial carcinoma (UTUC) after nephroureterectomy and relate these to patient outcomes. Methods: A database was created with 1029 patients undergoing radical nephroureterectomy for UTUC between 1994 and 2009 at 10 Canadian centres. Demographic, clinical and pathological variables were collected from chart review. Practice pattern variables were defined as: open versus laparoscopic nephroureterectomy, management strategy for the distal ureter, performance of lymphadenectomy and administration of chemotherapy and/or radiation therapy. The outcome measures were overall (OS), disease-specific (DSS) and recurrence-free survival (RFS). The centres were divided into three regions (West, Central, East). Cox proportional multivariable linear regression analysis was used to determine the association between regional differences in practice patterns and clinical outcomes. Results: There was a significant difference in practice patterns between regions within Canada for: time from diagnosis to surgery (p = 0.001), type of surgery (open vs. laparoscopic, p < 0.01) and method of management of the distal ureter (p = 0.001). As well, there were significant differences in survival between regions across Canada: 5-year OS (West 70%, Central 81% and East 62%, p < 0.0001) and DSS (West=79%, Central=85%, East=75%, p = 0.007) were significantly different, but there was no difference in RFS (West 47%, Central 48%, East 46%, p = 0.88). Multivariable linear regression analysis demonstrated that the differences in survival were independent of region OS (p = 0.78), DSS (p = 0.30) or RFS (p = 0.43). Conclusion: There is significant disparity in practice patterns between regions within Canada, but these do not appear to have an effect on survival. We believe that the variability in practice is a reflection of the lack of standardized treatments for UTUC and underlines the need for multi-institutional studies in this disease.

Current Status of Lymphadenectomy During Radical Nephroureterectomy for Upper Tract Urothelial Cancer—Yes, No or Maybe?

“…While the risks/benefits of lymphadenectomy are still being debated, the actual proportion of patients undergoing simultaneous lymphadenectomy during NU is very limited. In 2012, the Canadian Upper Tract Collaboration (CUTC) summarised different practice patterns zone wise across 10 institutions and included data of 1029 patients of UTUC [19]. Proportions of patients with pNx nodal stage were 69%, 80% and 70% across central, east and western regions of the country, respectively.…”

Peer Review #2 of "Long-term oncologic outcomes of laparoscopic nephroureterectomy versus open nephroureterectomy for upper tract urothelial carcinoma: a systematic review and meta-analysis (v0.1)"

“…3). Five studies including LNU (n=1126) and ONU (n=1403) (Ariane et al 2012;Fairey et al 2013;Favaretto et al 2010;Metcalfe et al 2012;Terakawa et al 2008) reported the UnRFS. The pooled analysis of the available HRs showed that the different surgical procedures were not significantly correlated with disease recurrence (HR 1.10, 95% CI: 0.93-1.28; P = 0.337, I 2 = 12.0%; Fig.…”

“…Among the four studies that provided the HRs of OS, there were 1442 LNU patients and 3119 ONU patients. (Fairey et al 2013;Kim et al 2015;Metcalfe et al 2012;Rieken et al 2014) There was significant heterogeneity ( P = 0.091, I 2 = 53.7%; Fig. 5), and a random model was applied.…”

Can lymphovascular invasion replace the prognostic value of lymph node involvement in patients with upper tract urothelial carcinoma after radical nephroureterectomy?

“…[1][2][3][4][5] Approximately 20-40% of patients initially present with locally advanced disease and lymph node (LN) metastases at the time of diagnosis. [6][7][8][9] Recently, Margulis et al identified age, high tumour grade, high pathological T stage, LN metastasis, sessile architecture, an infiltrative growth pattern, and lymphovascular invasion (LVI) as independent prognostic indicators of disease recurrence and cancer-specific survival (CSS).…”