Action Points

An analysis of U.S. trends and outcomes in the management of small kidney cancers now shows that surgery continues to be the most common treatment, with nephron-sparing surgery exceeding radical nephrectomy.

A study of the national Surveillance, Epidemiology, and End Results (SEER) registry (2001-2009) data also revealed that while nonsurgical management is a reasonable treatment strategy for elderly patients or those with limited life expectancy, its use remains low, William C. Huang, MD, department of urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, and colleagues report in the July JAMA Surgery.

"Although our findings support nonsurgical management as an acceptable treatment option for small kidney tumors in elderly patients or those with limited life expectancy," said Huang, "it appears that nonsurgical management of small kidney cancers remains uncommon and stable over time." He added that heightened awareness of outcomes from studies such as this may increase the use of nonsurgical management.

In the population-based cohort study, SEER cancer registry data linked to Medicare claims were used to identify patients 66 years or older with a diagnosis of primary renal-cortical tumor (<4 cm; International Classification of Diseases for Oncology, Third Edition topography codes C64 and C64.9)

Results show that overall survival (OS) was better in patients who received surgical treatment than in those who received nonsurgical management. However, only nephron-sparing surgery was associated with a benefit in cancer-specific survival (adjusted hazard ratio, 0.47; 95% CI, 0.31-0.69; P<0.001).

"...[O]ur analysis demonstrates that radical nephrectomy is no longer the treatment of choice for small kidney cancers," said Huang. "Expert guidelines for the management of small renal masses, such as those published by the American Urological Association in 2009, appear to have bolstered the paradigm shift away from radical nephrectomy toward nephron-sparing options for such tumors."

The same practice guidelines also offer ablation and surveillance as alternative treatment options for small kidney masses, noted Huang.

Analysis was performed between February 1, 2014, and December 31, 2014. The likelihood of receiving no surgery versus surgical intervention was analyzed as a function of demographic and disease characteristics, as well as the relationships between treatment approach and overall and cancer-specific survival.

Partial nephrectomy and ablation were combined and classified as nephron-sparing surgery and nonsurgical management was defined as the absence of any claim for one of these procedures in the first six months following diagnosis.

During the study period, 3,709 of the patients (61.9%) who underwent surgery had radical nephrectomy, and 2,285 patients (38.1%) had a nephron-sparing procedure.

Out of a total of 6,664 patients, the following outcomes and management trends were observed:

• 5,994 (90.0%) underwent surgery
• 670 patients (10.0%) were managed nonsurgically
• Use of radical nephrectomy decreased from 69%-42.5%
• Use of nephron-sparing surgery (partial nephrectomy and ablation) increased (from 21.5% to 49.0%)
• Proportion of patients who did not undergo surgery remained stable (9.5% and 8.5%)

During a median follow-up of 63 months (interquartile range, 43-89 months), 2,119 patients (31.8%) died, including 293 (4.4%) of kidney cancer, said the investigators.

"Our findings underscore the importance of competing causes of mortality in this population: 38.1% of patients died during the study period, but only 4.4% of patients died from kidney cancer," said Huang.

Differences in overall survival may reflect patient selection rather than a direct benefit of surgery, as highlighted by the greater risk of mortality observed soon after diagnosis in the cohort managed non-surgically, he said.

"Survival outcomes of partial nephrectomy appear to be at least equivalent and potentially superior in the short-term (median, 63 months) compared with radical nephrectomy, according to Huang. "Practically, the support for partial nephrectomy is bolstered both by patients hoping to preserve as much kidney as possible to prevent the burdens of hemodialysis and the urologist who has benefited from improvements in surgical experience."

With controls for demographic and disease characteristics as well as co-morbid conditions, patients whose care was managed non-surgically were more likely to be older, male, and nonwhite and to reside in the Western United States. Hypertension was associated with a greater likelihood of being treated surgically, and a prior non-kidney cancer diagnosis was associated with a greater likelihood of nonsurgical management, said Huang.

With a median follow-up of 57 months (inter-quartile range, 43-89 months), 136 patients (20.3%) who initially received nonsurgical treatment underwent surgery more than 6 months after diagnosis.

"Although our findings support nonsurgical management as an acceptable treatment option for small kidney tumors in elderly patients or those with limited life expectancy," said Huang, "it appears that nonsurgical management of small kidney cancers remains uncommon and stable over time." He added that heightened awareness of outcomes from studies such as this may increase the use of nonsurgical management.

"The authors establish partial nephrectomy as the new standard of treatment for small renal masses (SRMs) with the frequency of nephron-sparing surgery eclipsing that of radical nephrectomy in 2009," Joshua J. Meeks, MD, PhD, department of urology, Feinberg School of Medicine, Northwestern University, Chicago, IL., and colleagues point out in an accompanying editorial "Standard of Care for Small Renal Masses in the 21st Century" in JAMA Surgery.

Meeks noted that despite an overall increase in surgery for SRMs, the survival for patients with kidney cancer has not changed. In this study, a consistent 10.0% of tumors were actively monitored and these tumors were more likely to occur, he said.

"In older and unhealthy patients with overall survival of only 57.5% at the completion of the study, it is unclear how many masses were identified by imaging but not biopsied and therefore potentially not identified by the SEER registry," said Meeks.

"At some point," he emphasized, "every metastatic cancer must have been an SRM. As we learn more about the molecular signature of renal cancer and the mutations that drive progression, we will likely be managing SRMs differently in the near future."

The authors disclosed no relationships with industry.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine

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Due to high rates of diabetes, high blood pressure and heart disease, African-Americans have an increased risk of developing kidney failure, also known as renal failure. To help impaired renal function, experts say patients must have dialysis treatment.

According to the National Kidney Foundation, African-Americans constitute more than 32 percent of all patients in the U.S. receiving dialysis for kidney failure, but only represent 13 percent of the overall U.S. population.

Though African-American patients get the treatment they need, Dr. Michael Kraus, clinical chief of nephrology at Indiana University (IU) Health said Black dialysis patients are also disproportionate in the type of treatment they are offered.

"The majority of people in the U.S. go to in-center dialysis. In my opinion this is the worst form of therapy we have for end-stage renal disease. The best form of therapy is transplantation, but l-in-4 people with kidney failure will receive a transplant, and the odds are greater if one is minority. In the meantime, patients should be able to have the option to do in-home dialysis. It just gives patients a better quality of life," said Kraus who is also the director of the home dialysis unit at IU Health.

Those who do in-center dialysis visit their site three days a week for three to four hours. Once there, patients are hooked up to a machine that performs functions the body does naturally and daily. Once home, Kraus said the average dialysis patient feels exhausted and ill for about six to eight hours.

Attending dialysis on one's exact day and time is mandatory for even a modicum of normalcy and longer life expectancy.

The opposite is true for patients who do dialysis in the privacy of their home. Kraus said patients do dialysis five to seven times a week oftentimes while they sleep. These patients are able to lead a more normal lifestyle, aren't hospitalized as much and live longer, happier lives. Just ask Jarvis Burts.

Burts said he was unaware he suffered from high blood pressure. In 2010, the then 3 6-year-old began to feel ill and suffered from shortness of breath. Those symptoms prompted him to see a doctor. It was there he received the bad news. Not only did he have hypertension, he was told his kidneys were failing.

To save what was left of his kidneys, he began going to in-center dialysis three days a week.

"It was the worst days of my life. The service was bad and when I got home, all I could do was sleep because I felt so bad," said Burts. "And the days I wasn't at dialysis, my toxins would build up so that made me feel bad too. It just wasn't for me."

Shortly after his diagnosis, Burts discovered in-home therapy and transitioned to that form of treatment. He does his treatments daily at a time that's convenient for him. He said he is much happier and productive.

Burts has found success with in-home dialysis, however he is only one of a small number of Blacks who take advantage of the option. According to a recent survey, white patients are 2.2 times more likely to transition to in-home therapy than non-whites. African-Americans are four times less likely to be on any form of home dialysis.

Kraus said the reasons Blacks don't participate varies.

A major, unfortunate reason is because physicians unintentionally discriminate when prescribing the course of treatment for minorities.

"They don't think they're doing it, but some treat their Black patients different from their white patients," said Kraus. "I don't think its on purpose, though."

Physicians might assume patients are low-income, but Kraus said in-home dialysis is affordable for all patients.

In the medical field of nephrology, there aren't many African-American physician advocates on the front lines either. In addition, patients who aren't in networks that offer in-home therapy must be referred to those programs. Many physicians don't want to lose patients and therefore don't give them an in-home option.

Black patients must look at the "man in the mirror" for another reason why African-Americans don't take advantage of in-home therapy. Kraus said some patients believe a professional should administer the therapy. Patients are thoroughly trained prior to in-home dialysis.

Kraus hopes other physicians find the value of in-home dialysis and shares that information with patients. The best way to reduce disproportions amongst dialysis patients is for them to become empowered, take charge of their health care needs by becoming more educated about their options and choose the best form of therapy for them.

For those who are skeptical on other issues, Kraus assures that there's no difference in cost, and the equipment is not a burden on the home's utilities.

What could improve the status of African-American renal failure patients even more is if more Blacks, either alive or deceased, donate healthy, functioning kidneys to those who need them most.

Until then, in-home dialysis is a good option.

"Daily dialysis may seem strenuous, but in the long run, it makes you feel better," said Burts.

What are the kidneys and what do they do?

The kidneys are two bean-shaped organs, each about the size of a fist. They are located just below the rib cage, one on each side of the spine. Every day, the two kidneys filter about 120 to 150 quarts of blood to produce about 1 to 2 quarts of urine, composed of wastes and extra fluid. The urine flows from the kidneys to the bladder through two thin tubes of muscle called ureters, one on each side of the bladder. The bladder stores urine. The muscles of the bladder wall remain relaxed while the bladder fills with urine. As the bladder fills to capacity, signals sent to the brain tell a person to find a toilet soon. When the bladder empties, urine flows out of the body through a tube called the urethra, located at the bottom of the bladder. In men the urethra is long, while in women it is short.

Source: National Institute of Diabetes and Digestive and Kidney Diseases.

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