Long-term Survival Following Partial vs Radical Nephrectomy Among Older Patients With Early-Stage Kidney Cancer

Abstract

Context Although partial nephrectomy is the preferred treatment for many patients with early-stage kidney cancer, recent clinical trial data, which demonstrate better survival for patients treated with radical nephrectomy, have generated new uncertainty regarding the comparative effectiveness of these treatment options.Objective To compare long-term survival after partial vs radical nephrectomy among a population-based patient cohort whose treatment reflects contemporary surgical practice. Design, Setting, and PatientsWe performed a retrospective cohort study of Medicare beneficiaries with clinical stage T1a kidney cancer treated with partial or radical nephrectomy from 1992 through 2007. Using an instrumental variable approach to account for measured and unmeasured differences between treatment groups, we fit a 2-stage residual inclusion model to estimate the treatment effect of partial nephrectomy on long-term survival. Main Outcome MeasuresOverall and kidney cancer-specific survival.Results Among 7138 Medicare beneficiaries with early-stage kidney cancer, we identified 1925 patients (27.0%) treated with partial nephrectomy and 5213 patients (73.0%) treated with radical nephrectomy. During a median follow-up of 62 months, 487 (25.3%) and 2164 (41.5%) patients died following partial or radical nephrectomy, respectively. Kidney cancer was the cause of death for 37 patients (1.9%) treated with partial nephrectomy, and 222 patients (4.3%) treated with radical nephrectomy. Patients treated with partial nephrectomy had a significantly lower risk of death (hazard ratio [HR], 0.54; 95% CI, 0.34-0.85). This corresponded with a predicted survival increase with partial nephrectomy of 5.6 (95% CI, 1.9-9.3), 11.8 (95% CI, 3.9-19.7), and 15.5 (95% CI, 5.0-26.0) percentage points at 2, 5, and 8 years posttreatment (PϽ.001). No difference was noted in kidney cancer-specific survival (HR, 0.82; 95% CI, 0.19-3.49). ConclusionAmong Medicare beneficiaries with early-stage kidney cancer who were candidates for either surgery, treatment with partial rather than radical nephrectomy was associated with improved survival.

Survival after partial and radical nephrectomy for high-risk disease: A propensity-matched comparison

“…2 A recent instrumental variable analysis, which adjusts for selection bias and confounders -both known and unknown -in observational studies, arrived at similar results, with a 16% reduction in all-cause mortality attributed to PN. 21 This survival benefit is attributed to improved renal and cardiovascular functional outcomes with PN. 3,17,18 Four observational studies, using data from 1976-2008, have examined the outcomes of PN for high-risk disease.…”

Patterns of care for renal surgery: Underutilization of nephron-sparing procedures

“…A more recent SEER Medicare analysis suggested better long-term survival with partial nephrectomy. 11 The issue remains controversial, but AUA guidelines recommend a partial nephrectomy for smaller masses. However, according to our data, in 2009, 28.6% and 31.2% of patients underwent a nephronsparing procedure for renal mass in Virginia and Kentucky, respectively.…”

Advanced kidney carcinoma: decision paths and therapeutic perspectives

“…Circa i tre quarti delle nuove diagnosi riguardano neoplasie localizzate, passibili di trattamenti chirurgici a scopo curativo quali la nefrectomia radicale o, in alternativa, metodiche conservative nephron sparing; per queste ultime vi sono evidenze di beneficio in termini di sopravvivenza e qualità di vita, soprattutto nel caso di neoplasie di ridotte dimensioni [5,6]. Ad oggi non sono disponibili trattamenti adiuvanti o neoadiuvanti di sicura efficacia, sebbene alcuni farmaci siano in corso di sperimentazione clinica.…”

“…Ciò dipende dalla peculiare capacità delle cellule tumorali di espellere i chemioterapici, ereditata dai tubuli renali da cui il carcinoma origina, i quali sono normalmente deputati all' estromissione delle sostanze tossiche dall' organismo e alla detossificazione [2,3]. Ciò rappresenta un problema non di poco conto, se consideriamo che il tumore renale costituisce il 3-4% di tutte le neoplasie maligne, con circa 10.600 nuove diagnosi stimate nell'ultimo anno in Italia, 7.000 tra gli uomini e 3.600 tra le donne [4].Circa i tre quarti delle nuove diagnosi riguardano neoplasie localizzate, passibili di trattamenti chirurgici a scopo curativo quali la nefrectomia radicale o, in alternativa, metodiche conservative nephron sparing; per queste ultime vi sono evidenze di beneficio in termini di sopravvivenza e qualità di vita, soprattutto nel caso di neoplasie di ridotte dimensioni [5,6]. Ad oggi non sono disponibili trattamenti adiuvanti o neoadiuvanti di sicura efficacia, sebbene alcuni farmaci siano in corso di sperimentazione clinica.…”