Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era

Abstract

We sought to analyze utilization and survival outcomes of cytoreductive nephrectomy in patients with metastatic renal cell carcinoma (RCC) before and after introduction of targeted therapy. We identified patients with metastatic RCC between 1993 and 2010 in the SEER registry and examined temporal trends in utilization. We performed a joinpoint regression to determine when changes in utilization of cytoreductive nephrectomy occurred. We fitted multivariable proportional hazard models in full and propensity score-matched cohorts. We performed a difference-in-difference analysis to compare survival outcomes before and after introduction of targeted therapy. The proportion of patients undergoing cytoreductive nephrectomy increased from 1993 to 2004, from 29% to 39%. We identified a primary joinpoint of 2004, just prior to the introduction of targeted therapy. Beginning in 2005, there was a modest decrease in utilization of cytoreductive nephrectomy. Cytoreductive nephrectomy was associated with a lower adjusted relative hazard (0.41, 95% confidence interval 0.34 to 0.43). Median survival among patients receiving cytoreductive nephrectomy increased in the targeted therapy era (19 versus 13 months), while median survival among patients not receiving cytoreductive nephrectomy increased only slightly (4 versus 3 months). Difference-in-difference analysis showed a significant decrease in hazard of death among patients who received cytoreductive nephrectomy in the targeted therapy era. Despite decreased utilization in the targeted therapy era, cytoreductive nephrectomy remains associated with improved survival. Prospective randomized trials are needed to confirm the benefit of cytoreductive nephrectomy among patients with metastatic RCC treated with novel targeted therapies.

Cytoreductive Surgery in the Management of Renal Tumours: Rationale, Current Evidence and Future Perspectives

“…Though the rate of CRN improved after 2001 perhaps with the results of the EORTC and SWOG trials [10,11], it appears that there was a steady decrease in its use which peaked at 39% in 2004 and has decreased every year by 0.6% since then [19]. Tsao et al also showed a similar pattern in their study in the targeted therapy era, but it is difficult to infer that this was a global phenomenon as both these studies were based on the Surveillance, Epidemiology, and End Results (SEER) data analysis from the USA [20].…”

“…A large study using the SEER database examined CRN and survival in the era of immunotherapy as well as TT and found an overall survival of 19 months for TT with CRN versus only 4 months of TT [19]. This study also inferred that the median OS amongst the patients receiving CRN improved from 13 to 19 months between the era of immunotherapy (1993)(1994)(1995)(1996)(1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)) and the era of targeted therapy (2005)(2006)(2007)(2008)(2009)(2010) and there was no significant difference in OS in these two eras in patients who did not undergo CRN.…”

Palliative nephrectomy until targeted therapy of disseminated kidney cancer patients

“…Появление таргетных препаратов, ингибиру-ющих сосудистый эндотелиальный фактор роста (VEGF) и мишень рапамицина млекопитающих (mTOR), позволило существенно улучшить прогноз и принципиально изменить стандарты лекарственно-го лечения больных распространенным раком почки [5]. При этом необходимость выполнения циторедук-тивных вмешательств пациентам, являющимся кан-дидатами для таргетной терапии, в рандомизирован-ных исследованиях не доказана [6].…”

“…Пере-рыв и отмена лечения из-за тяжелых нежелательных явлений чаще также требовались неоперированным пациентам (20,0 %) по сравнению с больными, кото-рым была выполнена паллиативная нефрэктомия (4,2 %), однако разница результатов между группами не достигла статистической значимости. В немногочи-сленных ретроспективных исследованиях, изучавших результаты таргетной терапии с паллиативной нефрэк-томией и без нее, токсичность и безопасность лекарст-венного лечения в группах не сравнивались [6,[17][18][19][20].…”

“…В крупном регистровом исследовании Surveillance Epidemiology and End Results (SEER), изучавшем вли-яние циторедуктивной нефрэктомии на прогноз боль-ных, получавших любое системное лечение, ОВ паци-ентов, которым проводилась таргетная терапия, также возрастала при выполнении хирургического вмеша-тельства с 4 до 19 мес [6].…”