Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis

Abstract

Purpose Two randomized trials published in 2001 provided level 1 evidence for the use of cytoreductive nephrectomy (CyNx) for the treatment of metastatic renal cell carcinoma (mRCC). However, the regulatory approval of vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) in 2005 has left an “evidence void” regarding the use of CyNx. We evaluated the patterns in the use of CyNx in the cytokine and VEGFR-TKI eras, and the patient characteristics associated with the use of CyNx. Methods The Surveillance, Epidemiology, and End Results registry was used to identify patients with histologically or cytologically confirmed stage IV RCC between 2001 and 2008. Patients were classified as treated during the cytokine (2001–2005) or VEGFR-TKI (2006–2008) eras. A multivariate logistic regression analysis was performed to calculate the odds of undergoing CyNx according to treatment era and socioeconomic characteristics. Results Overall, 1,112 of 2,448 patients (45 %) underwent CyNx. CyNx use remained stable between 2001 and 2005 (50 %), but decreased to 38 % in 2008. Logistic regression analysis revealed that older age (OR 0.82, 95 % CI: 0.68, 0.99), black race (OR 0.64, 95 % CI: 0.46, 0.91), Hispanic ethnicity (OR 0.71, 95 % CI: 0.54, 0.93), and treatment in the VEGFR-TKI era (OR 0.82, 95 % CI: 0.68, 0.99) were independently associated with decreased use of CyNx. Conclusions Use of CyNx in the United States has declined in the VEGFR-TKI era. Older patients and minorities are less likely to receive CyNx. Results of ongoing phase III trials are needed to refine the role of this treatment modality.

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

“…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].…”

Mortality trends and the impact of lymphadenectomy on survival for renal cell carcinoma patients with distant metastasis

“…14 Therefore, level one evidence on the effect of LND on survival in mRCC could be readily obtained by randomizing the practice of LND into randomized control trials already planning to evaluate new systemic agents. 15 Until then, if LND can be performed without increasing morbidity, select patients may benefit from this additional surgical extirpation.…”

Cytoreductive nephrectomy and its role in the present-day period of targeted therapy

“…The continued use of CN in the multimodal management of patients with mRCC is supported by the fact that in studies evaluating targeted therapy, the majority (67-100%) of patients had undergone nephrectomy prior to initiation of systemic therapy [Escudier et al 2007[Escudier et al , 2010Hudes et al 2007;Motzer et al 2007;Rini et al 2010;Sternberg et al 2010;Tsao et al 2013]. In the prospective randomized trial evaluating sunitinib versus IFNα, a subgroup analysis found that PFS was increased in patients undergoing CN compared with patients treated with sunitinib alone (11 versus 6 months) [Motzer et al 2007].…”

“…Since targeted therapeutics would in theory treat all tumor sites and based on a lack of definitive data showing that nephrectomy may alter outcomes in conjunction with targeted therapy, it would seem reasonable that usage of CN may decrease. In fact, studies have shown that rates of CN decreased somewhat after the introduction of targeted therapy in 2005, although the demographics of the surgery population largely remained the same [Tsao et al 2013;Conti et al 2014]. Patients with mRCC most likely to have undergone CN in the immunotherapy era and early years of targeted therapy were younger, white, male, and had higher stage tumors [Tsao et al 2013;Culp et al 2014].…”

“…In fact, studies have shown that rates of CN decreased somewhat after the introduction of targeted therapy in 2005, although the demographics of the surgery population largely remained the same [Tsao et al 2013;Conti et al 2014]. Patients with mRCC most likely to have undergone CN in the immunotherapy era and early years of targeted therapy were younger, white, male, and had higher stage tumors [Tsao et al 2013;Culp et al 2014]. Nonetheless, CN usage after 2005 remained greater than 35% indicating that, at least initially, there was an a priori assumption that the survival benefit of CN would be present regardless of the type of systemic therapy a patient received.…”