Personalized Treatment for Small Renal Tumors: Decision Analysis of Competing Causes of Mortality

Abstract

To compare the effectiveness of personalized treatment for small (4 cm) renal tumors versus routine partial nephrectomy (PN), accounting for various competing causes of mortality. Materials and Methods: A state-transition microsimulation model was constructed to compare life expectancy of management strategies for small renal tumors by using 1 000 000 simulations in the following ways: routine PN or personalized treatment involving percutaneous ablation for risk factors for worsening chronic kidney disease (CKD), and otherwise PN; biopsy, with triage of renal cell carcinoma (RCC) to PN or ablation depending on risk factors for worsening CKD; active surveillance for growth; and active surveillance when MRI findings are indicative of papillary RCC. Transition probabilities were incorporated from the literature. Effects of parameter variability were assessed in sensitivity analysis. Results: In patients of all ages with normal renal function, routine PN yielded the longest life expectancy (eg, 0.67 years in 65-year-old men with nephrometry score [NS] of 4). Otherwise, personalized strategies extended life expectancy versus routine PN: in CKD stages 2 or 3a, moderate or high NS, and no comorbidities, MRI guidance for active surveillance extended life expectancy (eg, 2.60 years for MRI vs PN in CKD 3a, NS 10); and with Charlson comorbidity index of 1 or more, biopsy or active surveillance for growth extended life expectancy (eg, 2.70 years for surveillance for growth in CKD 3a, NS 10). CKD 3b was most effectively managed by using MRI to help predict papillary RCC for surveillance. Conclusion: For patients with chronic kidney disease and small renal tumors, personalized treatment selection likely extends life expectancy.

An Evaluation of a Web-Based Decision Aid for Treatment Planning of Small Kidney Tumors: Pilot Randomized Controlled Trial

“…Therefore, we set out to determine the optimal management strategies for patients with SKMs and create evidence-based, patient-centered tools to communicate personalized harms and benefits of treatment options and promote shared decision-making. A decision-analytic model was developed to identify the key parameters, provide thresholds for variables affecting the decision (eg, test performance characteristics needed to improve outcomes), and assess the sensitivity of the decision to patient preferences [ 8 ]. We then interfaced the favored treatment options in accordance with patient and tumor characteristics with a decision aid (DA).…”

Clinical outcomes and effect on intraoperative blood loss and postoperative pain of patients undergoing retroperitoneal laparoscopic partial nephrectomy for complex renal tumors

“…The renal tumor is a common type of urinary system tumors with the incidence rate that ranks only second to bladder cancer. As the biological behavior capacity of renal tumor is low, such disease is relatively less malignant and less prone to metastasis, with well-defined lesion borders and slow growth [ 1 , 2 ]. The continuous progress of medical diagnosis techniques in recent years has improved the early diagnosis rate of renal tumors and realized a desirable clinical prognosis.…”

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“…TA extended life expectancy in patients with CKD stage 3A, RENAL nephrometry score less than 7 and Charlson comorbidity index greater than or equal to 1. Patients with more aggressive tumors (RENAL nephrometry score ≥ 7) and CKD stage 3B benefited from watchful waiting or MRI surveillance to detect papillary type 1 RCC (i.e., well-circumscribed cortical masses with T2-weighted hypointensity and low-level enhancement) which would have minimal oncologic benefit with treatment due to low probability of tumor progression [14].…”