Evaluation of the National Comprehensive Cancer Network and American Urological Association Renal Cell Carcinoma Surveillance Guidelines

Abstract

A B S T R A C T PurposeThe National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). Herein, we assess the ability of the guidelines to capture RCC recurrences and determine the duration of surveillance required to capture 90%, 95%, and 100% of recurrences. Patients and MethodsWe evaluated 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared. ResultsAt a median follow-up of 9.0 years (interquartile range, 5.7 to 14.4 years), a total of 1,088 patients (29.8%) experienced a recurrence. Of these, 390 recurrences (35.9%) were detected using 2013 NCCN recommendations, 742 recurrences (68.2%) were detected using 2014 NCCN recommendations, and 728 recurrences (66.9%) were detected using AUA recommendations. All protocols missed the greatest amount of recurrences in the abdomen and among pT1Nx-0 patients. To capture 95% of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were $1,228.79 using 2013 NCCN, $2,131.52 using 2014 NCCN, and $1,738.31 using AUA guidelines. However, if 95% of LR-partial recurrences were captured, costs would total $9,856.82. ConclusionIf strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.

Low yield of surveillance imaging after surgery for T1 kidney cancer

“…[12] Similar to our study, the authors found a high rate of relapses beyond 3 years. In contrast to our findings, these authors found that current guidelines will miss a large number of relapses, particularly for low-risk patients and patients with abdominal relapses.…”

Genomic landscape and evolution of metastatic chromophobe renal cell carcinoma

“…Due to the rarity (~5% of RCC) and the low (5%-10%) incidence of eventual metastases, only limited clinical parameters such as tumor sizes and sarcomatoid changes were shown to affect clinical outcome (40), and no specific follow-up guideline has been developed for chRCC patients. Currently, nonmetastatic RCC patients of all histological subtypes after surgery were followed according to contemporary guidelines that are generalized and formulated based on integrated prognostic algorithms developed for ccRCC (41,42). Within the TCGA-KICH cohort, patients whose primary tumors exhibited none of the 3 high-risk features, i.e., TP53 mutations, PTEN mutations, or ICD, had a 5-year OS of 97%, whereas those with any had a 5-year OS of 74%.…”

Kidney Cancer, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology

“…Results from a retrospective analysis indicate that in a subset of patients, relapses occur >5 years after surgery for their primary RCC. 77 The analysis suggests that continued follow-up/surveillance after 5 years may be of potential value in some patients. Identification of subsets of patients with higher risk who require longer follow-up has not been defined, and further research is required to refine follow-up strategies for patients with RCC.…”