Racial disparities in overall survival among renal cell carcinoma patients with young age and small tumors

Characterization of Demographical Histologic Diversity in Small Renal Masses With the Clear Cell Likelihood Score

OBJECTIVE

This study aimed to develop a diagnostic model to estimate the distribution of small renal mass (SRM; ≤4 cm) histologic subtypes for patients with different demographic backgrounds and clear cell likelihood score (ccLS) designations.

MATERIALS AND METHODS

A bi-institution retrospective cohort study was conducted where 347 patients (366 SRMs) underwent magnetic resonance imaging and received a ccLS before pathologic confirmation between June 2016 and November 2021. Age, sex, race, ethnicity, socioeconomic status, body mass index (BMI), and the ccLS were tabulated. The socioeconomic status for each patient was determined using the Area Deprivation Index associated with their residential address. The magnetic resonance imaging-derived ccLS assists in the characterization of SRMs by providing a likelihood of clear cell renal cell carcinoma (ccRCC). Pathological subtypes were grouped into four categories (ccRCC, papillary renal cell carcinoma, other renal cell carcinomas, or benign). Generalized estimating equations were used to estimate probabilities of the pathological subtypes across different patient subgroups.

RESULTS

Race and ethnicity, BMI, and ccLS were significant predictors of histology (all P < 0.001). Obese (BMI, ≥30 kg/m 2 ) Hispanic patients with ccLS of ≥4 had the highest estimated rate of ccRCC (97.1%), and normal-weight (BMI, <25 kg/m 2 ) non-Hispanic Black patients with ccLS ≤2 had the lowest (0.2%). The highest estimated rates of papillary renal cell carcinoma were found in overweight (BMI, 25-30 kg/m 2 ) non-Hispanic Black patients with ccLS ≤2 (92.3%), and the lowest, in obese Hispanic patients with ccLS ≥4 (<0.1%).

CONCLUSIONS

Patient race, ethnicity, BMI, and ccLS offer synergistic information to estimate the probabilities of SRM histologic subtypes.

Socioeconomic determinants of racial disparities in survival outcomes among patients with renal cell carcinoma

PURPOSE

Racially driven outcomes in cancer are challenging to study. Studies evaluating the impact of race in renal cell carcinoma (RCC) outcomes are inconsistent and unable to disentangle socioeconomic disparities from inherent biological differences. We therefore seek to investigate socioeconomic determinants of racial disparities with respect to overall survival (OS) when comparing Black and White patients with RCC.

METHODS

We queried the National Cancer Database (NCDB) for patients diagnosed with RCC between 2004 and 2017 with complete clinicodemographic data. Patients were examined across various stages (all, cT1aN0M0, and cM1) and subtypes (all, clear cell, or papillary). We performed Cox proportional hazards regression with adjustment for socioeconomic and disease factors.

RESULTS

There were 386,589 patients with RCC, of whom 46,507 (12.0%) were Black. Black patients were generally younger, had more comorbid conditions, less likely to be insured, in a lower income quartile, had lower rates of high school completion, were more likely to have papillary RCC histology, and more likely to be diagnosed at a lower stage of RCC than their white counterparts. By stage, Black patients demonstrated a 16% (any stage), 22.5% (small renal mass [SRM]), and 15% (metastatic) higher risk of mortality than White patients. Survival differences were also evident in histology-specific subanalyses. Socioeconomic factors played a larger role in predicting OS among patients with SRMs than in patients with metastasis.

CONCLUSIONS

Black patients with RCC demonstrate worse survival outcomes compared to White patients across all stages. Socioeconomic disparities between races play a significant role in influencing survival in RCC.

Racial disparities in nephrectomy and mortality among patients with renal cell carcinoma: Findings from SEER

PURPOSE

To assess racial differences in the receipt of nephrectomy in patients diagnosed RCC in the US.

MATERIALS AND METHODS

2005 to 2015 data from the SEER database was analyzed and 70,059 patients with RCC were identified. We compared demographic and tumor characteristics between black patients and white patients. We applied logistic regression to assess the association between race and the odds of the receipt of nephrectomy. We also applied Cox proportional hazards model to assess the impact of race on cancer-specific mortality (CSM) and all-cause mortality (ACM) in patients diagnosed with RCC in the US.

RESULTS

Black patients had 18% lower odds of receiving nephrectomy compared to white patients (p < 0.0001). The odds of the receipt of nephrectomy also reduced with age at diagnosis. In addition, patients with T3 stage had the greatest odds of receiving nephrectomy when compared to T1 (p < 0.0001). There was no difference in the risk of cancer-specific mortality between black patients and white patients; black patients had 27% greater odds of all-cause mortality than white patients (p < 0.0001). Patients who did not receive nephrectomy had a 42% and 35% higher risk of CSM and ACM respectively, when compared to patients who received nephrectomy.

CONCLUSIONS

Black patients diagnosed with RCC in the US have a greater ACM risk and are less likely than white patients to receive nephrectomy. Systemic changes are needed to eliminate racial disparity in the treatment and outcomes of RCC in the US.

Assessing the impact of socio-economic determinants on access to care, surgical treatment options and outcomes among patients with renal mass: Insight from the universal healthcare system

OBJECTIVE

To assess whether socio-economic disparities exist on access to care, treatment options and outcomes among patients with renal mass amenable of surgical treatment within the universal healthcare system.

METHODS

Data of consecutive patients submitted to partial nephrectomy (PN) or radical nephrectomy (RN) at our Institution between 2017 and 2020 were retrospectively evaluated. Patients were grouped according to their income level (low, intermediate, and high) based on the Indicator of Equivalent Economic Situation national criterion. Survival analysis was performed. Cox regression models were employed to analyse the impact of socio-economic variables on survival outcomes.

RESULTS

One thousand forty-two patients were included (841 PN and 201 RN). Patients at the lowest income level were found more likely symptomatic and with a higher pathological tumour stage in the RN cohort (p > 0.05). The guidelines adherence on surgical indication rate as well as the access to minimally invasive surgery did not differ according to patient's income level in both cohorts (p > 0.05). Survival curves were comparable among the groups. Cox regression analysis showed that none of the included socio-economic variables was associated with survival outcomes in our series.

CONCLUSIONS

Universal healthcare system may increase the possibility to ensure egalitarian treatment modalities for patients with renal cancer.

Contemporary vs historical survival rates in metastatic clear cell renal carcinoma according to race/ethnicity

PURPOSE

Systemic therapies (ST) improved contemporary survival rates, relative to historical in clear cell metastatic renal carcinoma (ccmRCC) patients. The magnitude of this improvement is unknown according to race/ethnicity.

METHODS

Within the SEER registry (2000-2017), ccmRCC patients were stratified according to race/ethnicity (Caucasian, Hispanic, African American, Asian) and historical (2000-2009) vs contemporary (2010-2017) years of diagnosis. Competing risks regression (CRR) with adjustment for other-cause mortality and Poisson smoothed cumulative incidence plots addressed cancer-specific mortality (CSM).

RESULTS

Of 10,141 mRCC patients, 4316 (43%) vs 5825 (57%) were diagnosed in historical vs contemporary era. Of 4316 historical patients, 3203 (74%) vs 593 (14%) vs 293 (7%) vs 227 (5%) were Caucasian, Hispanic, African American and Asian. Of 5825 contemporary patients, 4124 (71%) vs 977 (17%) vs 362 (6%) vs 362 (6%) were Caucasian, Hispanic, African American and Asian. Between 2000 and 2017, ST rates ranged from 12 to 57% in Caucasians, 2 to 57% in Hispanics, 33 to 50% in African Americans, 17 to 70% in Asians and universally increased toward a plateau in 2010. In Caucasians, CSM decreased from 80 to 74% vs 79 to 74% in Hispanics vs 79 to 77% in African Americans, but not in Asians (67-73%). Nonetheless, these rates translated into independent predictor status of contemporary years of diagnosis in all race/ethnicity groups: CSM hazard ratios of 0.75, 0.75, 0.73 and 0.80 in, respectively, Caucasian, Hispanic, African American and Asian.

CONCLUSIONS

In all race/ethnicity groups, contemporary ST rates increased and improved CSM rates have also been recorded.

Patient- And Provider-Level Predictors of Survival Among Patients With Metastatic Renal Cell Carcinoma Initiating Oral Anticancer Agents

PURPOSE

In an era of rapid expansion of FDA approvals for oral anticancer agents (OAAs), it is important to understand the factors associated with survival among real-world populations, which include groups not well-represented in pivotal clinical trials of OAAs, such as the elderly, racial minorities, and medically complex patients. Our objective was to evaluate patient- and provider-level characteristics' associations with mortality among a multi-payer cohort of metastatic renal cell carcinoma (mRCC) patients who initiated OAAs.

METHODS

This retrospective cohort study was conducted using data from the North Carolina state cancer registry linked to multi-payer claims data for the years 2004 to 2015. Provider data were obtained from North Carolina Health Professions Data System and the National Plan & Provider Enumeration System. Included patients were individuals with mRCC who initiated an OAA and survived ≥90 days after beginning treatment. We estimated hazard ratios (HR) and corresponding 95% confidence limits (CL) using Cox hazard models for associations between patient demographics, patient clinical characteristics, provider-level factors, and 2-year all-cause mortality.

RESULTS

The cohort included 207 patients with mRCC who received OAAs. In multivariable models, clinical variables such as frailty (HR: 1.36, 95% CL: 1.11-1.67) and de novo metastatic diagnosis (HR: 2.63, 95%CL: 1.67-4.16) were associated with higher all-cause mortality. Additionally, patients solely on Medicare had higher adjusted all-cause mortality compared with patients with any private insurance (HR: 2.35, 95% CL: 1.32-4.18). No provider-level covariates investigated were associated with all-cause mortality.

CONCLUSIONS

Within a real-world population of mRCC patients taking OAAs, survival differed based on patient characteristics. In an era of rapid expansion of FDA approvals for OAAs, these real-world data underscore the continued importance of access to high-quality care, particularly for medically complex patients with limited resources.

Survival Improvement in Patients with Renal Cell Carcinoma and Disparities between Different Sexes, Races, and Socioeconomic Status: 1977–2016

Objective

Rare research of renal cell carcinoma (RCC) has been made in a comprehensive and full description based on a long period of time as yet. This study was aimed at investigating the incidence and relative survival rates (RSRs) of RCC in the past forty years and to disclose the impact of sex, race, and socioeconomic status (SES) on RCC.

Methods

The data as variables, including age, gender, race, and SES, were obtained from the Surveillance, Epidemiology, and End Results (SEER) database. SES was divided into three levels: low poverty, medium poverty, and high poverty. The medium- and high-poverty groups were integrated into one group in all analyses. The RSRs were calculated using period analysis methodology. Summary statistics including incidence and RSRs were analyzed by Kaplan–Meier and Cox proportional hazards models with GraphPad Prism 8.0.1 software and Stata 12.0 software.

Results

A total of 77,513 patients diagnosed with RCC were enrolled in this study, showing an increased incidence and 10-year RSRs from 1977 to 2016. Patients older than 60 years had the highest incidence and the lowest RSRs. This research also showed significant disparities between different groups: incidence in males, blacks, and medium-high poverty groups was higher than that in females, whites, and low poverty groups, while RSRs were lower. For sex groups, the disparity of RSRs was obvious among patients who were 30–59 years old, but not among those younger than 29 years or older than 60 years. Based on SES, the survival gaps between different SES groups were getting wider over the past forty years.

Conclusion

This study showed how age, sex, race, and SES affected the incidence and RSRs of RCC, which may be beneficial for both better designed clinical trials and efficient prevention methods.

Disparities in Clinical Care and Research in Renal Cell Carcinoma

Disparities in cancer screening, prevention, therapy, clinical outcomes, and research are increasingly recognized and pervade all malignancies. In response, several cancer research and clinical care organizations have issued policy statements to acknowledge and address barriers to achieving health equity in cancer care. The increasingly specialized nature of oncology warrants a disease-focused appraisal of existing disparities and potential solutions. Although clear improvements in clinical outcomes have been recently observed for patients with renal cell carcinoma (RCC), these improvements have not been equally shared across diverse populations. This review describes existing RCC cancer disparities and their potential contributing factors and discusses opportunities to improve health equity in clinical research for all patients with RCC.

Disparities in Cancer Specific and Overall Survival Outcomes in African Americans With Renal Cell Carcinoma: Analysis From the International Marker Consortium for Renal Cancer (INMARC)

OBJECTIVE

To investigate association of African-American race and survival in Renal Cell Carcinoma (RCC).

PATIENTS AND METHODS

We queried the International Marker Consortium for Renal Cancer database for patients who underwent partial or radical (RN) nephrectomy. The cohort was divided into African American (AA) and non-African American (NAA) patients. Primary outcome was all-cause mortality. Secondary outcome was cancer-specific mortality. Multivariable Analysis and Kaplan-Meier Analysis were used to elucidate predictive factors and survival outcomes.

RESULTS

Three thousand eight hundred and ninety-three patients were analyzed (AA, n = 564/NAA, n = 3329). AA had greater Stage I (73.8% vs 63.9%, P <.001) and papillary RCC (29.8% vs 8.5%, P <.001). Multivariable Analysis revealed increasing age (HR = 1.03, P <.001), AA (HR = 1.24, P = .027), higher stage (HR = 1.30-3.19, P <.001), RN (HR = 2.45, P <.001), clear cell (HR = 1.23, P <.001), positive margin (HR = 1.34, P .004), and high-grade (HR = 1.58, P <.001) to be associated with worsened all-cause mortality. Increasing age (HR = 1.02, P <.001), AA (HR = 1.48, P = .025), RN (HR = 2.98, P <.001), high-grade (HR = 3.11, P <.001), and higher stage (HR = 3.03-13.2, P <.001) were predictive for cancer-specific mortality. Kaplan-Meier Analysis revealed worsened 5-year overall survival for AA in stage I (80% vs 88%, P = .001), stage III (26% vs 70%, P = .001), and stage IV (23% vs 44%, P = .009). Five-year cancer-specific survival was worse for AA in stage III (36% vs 81%, P <.001) and stage IV (30% vs 49%, P = .007).

CONCLUSION

Despite presenting with more indolent histology and lower stage, African-Americans were at greater risk for diminished survival, faring worse in overall survival for all stages and cancer-specific survival in for stage III/IV RCC. Further investigation into factors associated with these disparities is warranted.

Race/ethnicity and advanced stage of renal cell carcinoma in adults: results from surveillance, epidemiology, and end results program 2007-2015

Non-Hispanic Blacks were shown to have an earlier stage of renal cell carcinoma (RCC) at diagnosis compared to non-Hispanic Whites. It is less clear whether disparities in RCC staging occurs for other minority races/ethnicities. We aimed to assess the association between racial/ethnic minorities and stage at diagnosis of RCC, and test for potential effect modification by histological subtype. Sourced from the Surveillance, Epidemiology and End Results (SEER) database, patients ≥20 years diagnosed with RCC from 2007 to 2015 were included (n = 37 493). Logistic regression analyses were performed to assess the independent association between race/ethnicity [non-Hispanic White, non-Hispanic Black, non-Hispanic Asian Pacific Islander, non-Hispanic American Indian/Alaskan Native (AI/AN) and Hispanic] and advanced RCC stage at diagnosis (i.e. regional spread or distant metastasis). Interaction terms were tested and stratified regression was performed accordingly. Twenty-eight percent of patients had advanced RCC stage at diagnosis. After adjusting for age, gender, year of diagnosis, histological subtype and insurance status, compared to non-Hispanic Whites, non-Hispanic Blacks had lower odds of advanced stage at diagnosis [odds ratio (OR) = 0.79; 95% confidence interval (CI) = 0.72-0.87 for clear cell; OR = 0.48; CI = 0.30-0.78 for chromophobe and OR = 0.26; CI = 0.10-0.35 for other subtypes]. Higher odds of advanced stage at diagnosis were found for non-Hispanic AI/AN in clear cell (OR = 1.27; CI = 1.04-1.55) and for Hispanics in papillary subtypes (OR = 1.58; CI = 1.07-2.33). Racial disparities in the RCC stage at diagnosis varied according to histological subtype. Further investigation on the racial disparities reported is warranted to optimize detection and ultimately improve the prognosis of patients with RCC.

Impacts of Neighborhood Characteristics and Surgical Treatment Disparities on Overall Mortality in Stage I Renal Cell Carcinoma Patients

Racial/ethnic minority groups in the United States have high renal cell carcinoma (RCC) mortality rates. This study assessed surgical treatment disparities across racial/ethnic groups and impacts of neighborhood socioeconomic characteristics on surgical treatments and overall mortality. Stage I RCC patients diagnosed between 2004 and 2016 from National Cancer Database were included (n = 238,141). We assessed differences in associations between race/ethnicity and treatment patterns using logistic regression and between race/ethnicity and overall mortality using Cox regression with and without neighborhood characteristics in the regression models. When compared to non-Hispanic Whites (NHWs), American Indians/Alaska Natives and non-Hispanic Blacks (NHBs) were more likely not to receive surgical care and all racial/ethnic minority groups had significantly increased odds of undergoing radical rather than partial nephrectomy, even after adjusting for neighborhood characteristics. Including surgical treatment and neighborhood factors in the models slightly attenuated the association, but NHBs had a significantly increased risk of overall mortality. NHBs who underwent radical nephrectomy had an increased risk of mortality (HR 1.15, 95% CI: 1.08-1.23), but not for NHBs who underwent partial nephrectomy (HR 0.92, 95% CI: 0.84-1.02). Neighborhood factors were associated with surgical treatment patterns and overall mortality in both NHBs and NHWs. Neighborhood socioeconomic factors may only partly explain RCC disparities.

Self-reported quality of life as a predictor of mortality in renal cell carcinoma

BACKGROUND

This study evaluated the utility of self-reported quality of life (QOL) metrics in predicting mortality among all-comers with renal cell carcinoma (RCC) and externally tested the findings in a registry of patients with small renal masses.

METHODS

The Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) captured QOL metrics composed of mental component summary (MCS) and physical component summary (PCS) scores. Regression models assessed associations of MCS and PCS with all-cause, RCC-specific, and non-RCC-specific mortality. Harrell's concordance statistic (the C-index) and the Akaike information criterion (AIC) determined predictive accuracy and parsimony, respectively. Findings were tested in the prospective Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry.

RESULTS

In SEER-MHOS, 1494 patients had a median age of 73.4 years and a median follow-up time of 5.6 years. Each additional MCS and PCS point reduced the hazard of all-cause mortality by 1.3% (95% CI, 0.981-0.993; P < .001) and 2.3% (95% CI, 0.971-0.984; P < .001), respectively. Models with QOL metrics demonstrated higher predictive accuracy (C-index, 72.3% vs 70.1%) and parsimony (AIC, 9376.5 vs 9454.5) than models without QOL metrics. QOL metrics exerted a greater effect on non-RCC-specific mortality than RCC-specific mortality. External testing in the DISSRM registry confirmed these findings with similar results for all-cause mortality.

CONCLUSIONS

Models with self-reported QOL metrics predicted all-cause mortality in patients with RCC with higher accuracy and parsimony than those without QOL metrics. Physical health was a stronger predictor of mortality than mental health. The findings support the incorporation of QOL metrics into prognostic models and patient counseling for RCC.

A Review of Research on Disparities in the Care of Black and White Patients With Cancer in Detroit

Racial disparities in cancer incidence and outcomes are well-documented in the US, with Black people having higher incidence rates and worse outcomes than White people. In this review, we present a summary of almost 30 years of research conducted by investigators at the Karmanos Cancer Institute's (KCI's) Population Studies and Disparities Research (PSDR) Program focusing on Black-White disparities in cancer incidence, care, and outcomes. The studies in the review focus on individuals diagnosed with cancer from the Detroit Metropolitan area, but also includes individuals included in national databases. Using an organizational framework of three generations of studies on racial disparities, this review describes racial disparities by primary cancer site, disparities associated with the presence or absence of comorbid medical conditions, disparities in treatment, and disparities in physician-patient communication, all of which contribute to poorer outcomes for Black cancer patients. While socio-demographic and clinical differences account for some of the noted disparities, further work is needed to unravel the influence of systemic effects of racism against Black people, which is argued to be the major contributor to disparate outcomes between Black and White patients with cancer. This review highlights evidence-based strategies that have the potential to help mitigate disparities, improve care for vulnerable populations, and build an equitable healthcare system. Lessons learned can also inform a more equitable response to other health conditions and crises.

Demographic Factors Associated With Non-Guideline-Based Treatment of Kidney Cancer in the United States

Importance

Significant demographic disparities have been found to exist in the delivery of health care. Demographic factors associated with clinical decision-making in kidney cancer have not been thoroughly studied.

Objective

To determine whether demographic factors, including sex and race/ethnicity, are associated with receipt of non-guideline-based treatment for kidney cancer.

Design, Setting, and Participants

This retrospective cohort study was conducted using data from the National Cancer Database for the years 2010 through 2017. Included patients were individuals aged 30 to 70 years with localized (ie, cT1-2, N0, M0) kidney cancer and no major medical comorbidities (ie, Charlson-Deyo Comorbidity Index score of 0 or 1) treated at Commission on Cancer-accredited health care institutions in the United States. Data were analyzed from November 2020 through March 2021.

Exposures

Demographic factors, including sex, race/ethnicity, and insurance status.

Main Outcomes and Measures

Receipt of non-guideline-based treatment (undertreatment or overtreatment) for kidney cancer, as defined by accepted clinical guidelines, was determined.

Results

Among 158 445 patients treated for localized kidney cancer, 99 563 (62.8%) were men, 120 001 individuals (75.7%) were White, and 91 218 individuals (57.6%) had private insurance. The median (interquartile range) age was 58 (50-64) years. Of the study population, 48 544 individuals (30.6%) received non-guideline-based treatment. Female sex was associated with lower adjusted odds of undertreatment (odds ratio [OR], 0.82; 95% CI, 0.77-0.88; P < .001) and higher adjusted odds of overtreatment (OR, 1.27; 95% CI, 1.24-1.30; P < .001) compared with male sex. Compared with White patients, Black and Hispanic patients had higher adjusted odds of undertreatment (Black patients: OR, 1.42; 95% CI, 1.29-1.55; P < .001; Hispanic patients: OR, 1.20; 95% CI, 1.06-1.36; P = .004) and overtreatment (Black patients: OR, 1.09; 95% CI, 1.05-1.13; P < .001; Hispanic patients: OR, 1.06; 95% CI, 1.01-1.11, P = .01). Individuals who were uninsured, compared with those who had insurance, had statistically significantly higher adjusted odds of undertreatment (OR, 2.63; 95% CI, 2.29-3.01; P < .001) and lower adjusted odds of overtreatment (OR, 0.72; 95% CI, 0.67-0.77; P < .001).

Conclusions and Relevance

This study found that there were significant disparities in treatment decision-making for patients with kidney cancer, with increased rates of non-guideline-based treatment for women and Black and Hispanic patients. These findings suggest that further research into the mechanisms underlying these disparities is warranted and that clinical and policy decision-making should take these disparities into account.

Associations of Medicaid Expansion With Insurance Coverage, Stage at Diagnosis, and Treatment Among Patients With Genitourinary Malignant Neoplasms

IMPORTANCE

Health insurance coverage is associated with improved outcomes in patients with cancer. However, it is unknown whether Medicaid expansion through the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the diagnosis and treatment of patients with genitourinary cancer.

OBJECTIVE

To assess the association of Medicaid expansion with health insurance status, stage at diagnosis, and receipt of treatment among nonelderly patients with newly diagnosed kidney, bladder, or prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study included adults aged 18 to 64 years with a new primary diagnosis of kidney, bladder, or prostate cancer, selected from the National Cancer Database from January 1, 2011, to December 31, 2016. Patients in states that expanded Medicaid were the case group, and patients in nonexpansion states were the control group. Data were analyzed from January 2020 to March 2021.

EXPOSURES

State Medicaid expansion status.

MAIN OUTCOMES AND MEASURES

Insurance status, stage at diagnosis, and receipt of cancer and stage-specific treatments. Cases and controls were compared with difference-in-difference analyses.

RESULTS

Among a total of 340 552 patients with newly diagnosed genitourinary cancers, 94 033 (27.6%) had kidney cancer, 25 770 (7.6%) had bladder cancer, and 220 749 (64.8%) had prostate cancer. Medicaid expansion was associated with a net decrease in uninsured rate of 1.1 (95% CI, -1.4 to -0.8) percentage points across all incomes and a net decrease in the low-income population of 4.4 (95% CI, -5.7 to -3.0) percentage points compared with nonexpansion states. Expansion was also associated with a significant shift toward early-stage diagnosis in kidney cancer across all income levels (difference-in-difference, 1.4 [95% CI, 0.1 to 2.6] percentage points) and among individuals with low income (difference-in-difference, 4.6 [95% CI, 0.3 to 9.0] percentage points) and in prostate cancer among individuals with low income (difference-in-difference, 3.0 [95% CI, 0.3 to 5.7] percentage points). Additionally, there was a net increase associated with expansion compared with nonexpansion in receipt of active surveillance for low-risk prostate cancer of 4.1 (95% CI, 2.9 to 5.3) percentage points across incomes and 4.5 (95% CI, 0 to 9.0) percentage points among patients in low-income areas.

CONCLUSIONS AND RELEVANCE

These findings suggest that Medicaid expansion was associated with decreases in uninsured status, increases in the proportion of kidney and prostate cancer diagnosed in an early stage, and higher rates of active surveillance in the appropriate, low-risk prostate cancer population. Associations were concentrated in population residing in low-income areas and reinforce the importance of improving access to care to all patients with cancer.

Renal Cell Carcinoma Health Disparities in Stage and Mortality among American Indians/Alaska Natives and Hispanic Americans: Comparison of National Cancer Database and Arizona Cancer Registry Data

Simple Summary

This study assessed renal cell carcinoma disparities in American Indians/Alaska Natives and Hispanic Americans using the National Cancer Database and the Arizona Cancer Registry, focusing on advanced-stage and mortality. Renal cell carcinoma disparities in American Indians/Alaska Natives have been partially explained by neighborhood socioeconomic factors and residence (rural or urban) pattern, but not in Hispanic Americans. Greater health disparities in renal cell carcinoma stage and mortality for Hispanic Americans and renal cell carcinoma mortality for American Indians/Alaska Natives were observed at the Arizona state level compared to national levels.

Abstract

Renal cell carcinoma (RCC) is one of the top 10 cancers in the United States. This study assessed RCC health disparities in American Indians/Alaska Natives (AIs/ANs) and Hispanic Americans (HAs) focusing on advanced-stage and mortality. RCC patients’ data were obtained from the National Cancer Database (NCDB) and Arizona Cancer Registry (ACR). Logistic and Cox regression analyses were performed to ascertain the effect of race/ethnicity on stage and mortality, adjusting for neighborhood socioeconomic factors, rural/urban residence pattern, and other factors. In both data sets, AIs/ANs had significantly increased odds of advanced-stage RCC in the unadjusted model, but not in adjusted models. Mexican Americans had higher odds of advanced-stage compared to non-Hispanic Whites in NCDB (OR 1.22, 95% CI: 1.11–1.35) and ACR (OR 2.02, 95% CI: 1.58–2.58), even after adjusting for neighborhood characteristics. AIs/ANs did not show increased mortality risk in NCDB after adjusting for neighborhood characteristics, while the association remained significant in ACR (HR 1.33, 95% CI: 1.03–1.72). The great risk of all-cause and RCC-specific mortality was observed in U.S.-born Mexican Americans in Arizona (HR 3.21, 95% CI: 2.61–3.98 and sub-distribution HR 2.79, 95% CI: 2.05–3.81). RCC disparities in AIs/ANs is partially explained by neighborhood factors, but not in HAs.

The Association Between Race and 5-year Survival in Patients With Clear Cell Renal Cell Carcinoma: A Cohort Study

OBJECTIVE

To determine if race was associated with 5-year cause-specific survival in patients with clear cell renal cell carcinoma.

MATERIALS AND METHODS

Outcomes were investigated using the Surveillance Epidemiology and End Results database with data from 13 states between the years 2007-2015. Covariates included age, sex, insurance, marital status, and tumor stage at diagnosis. Patients <18 years old or with missing data for race, survival time or insurance status were excluded. Cox regression models were used to determine associations through hazard ratios (HR) with 95% confidence intervals (CI) and to adjust for covariates.

RESULTS

A total of 8421 subjects were included in the analysis. After adjustment, there was no association between race and 5-year cause-specific survival in patients with ccRCC (Black- HR: 0.96, 95%CI: 0.83,1.12; American Indian/Alaskan- HR: 1.01, 95%CI: 0.75,1.36; Asian Pacific Islander- HR: 0.99, 95%CI: 0.82,1.12). Older individuals and those with regional or distant tumors showed an increased hazard of death, while females and insured patients showed decreased hazard.

CONCLUSION

Our study found that race was not associated with 5-year cause-specific survival from clear cell renal cell carcinoma. However inferior overall survival in Blacks with RCC has been well demonstrated in the literature. Our findings suggest that differences in survival may not be driven by cause-specific factors such as renal cell carcinoma, but rather social determinants of health which disproportionality affect Black patients. Further studies with more power that incorporate information on income, comorbidities, education status, and access to care are therefore necessary.

Black race may be associated with worse overall survival in renal cell carcinoma patients

OBJECTIVE

To examine socio-demographic and treatment variables in an attempt to identify factors associated with survival differences between black and white patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

We identified 79,618 white and 10,604 black patients diagnosed with RCC in the National Cancer Database. We compared the distribution of socio-demographic, presentation and treatment variables between Blacks and Whites and then utilized a multivariable cox proportion hazards regression model to evaluate the contribution of differences in these variables to disparities in overall survival (OS).

RESULTS

Black patients were younger (60 vs. 63 years, P< 0.001) and with a lower stage (12.0% vs. 18.8% Stage III-IV P< 0.001). Blacks presented with a higher Charlson-Deyo score (P< 0.001), lower income (P< 0.001), lower education (P< 0.001) and were less likely to receive radical nephrectomy and systemic therapy for stage IV RCC (29.9% vs. 38.8%, P< 0.001). Unadjusted OS was lower for Whites (5-year survival 79% for Blacks and 77% for Whites). However, OS was lower for Blacks when adjusted for all variables (5-year survival 89% for Blacks and 93% for Whites). On multivariable analysis, black race was independently associated with worse OS, HR: 1.09 (95% confidence interval: 1.03, 1.14, P= 0.002). A sensitivity analysis including patients with complete data on tumor grade confirmed our results.

CONCLUSION

Our study indicates that black patients present at a younger age and with lower stage RCC, but have worse OS. Blacks experienced disparities in socio-demographic characteristics, clinical presentation, treatment-related factors, and had an independently increased hazard of death.

Race/Ethnicity and Survival in Metastatic Renal Cell Carcinoma: Outcomes for Patients Receiving First Line Targeted Therapies

BACKGROUND: No study to date has assessed the relationship between treatment-specific therapeutic outcomes and race/ethnicity in metastatic renal cell carcinoma (mRCC). As targeted therapies have formed the backbone of first-line treatment options for mRCC until very recently, we assessed the relationship between race/ethnicity and targeted therapy-related outcomes in mRCC. OBJECTIVE: To retrospectively compare response rates and survival outcomes across ethnicities in patients who received first-line targeted therapies for mRCC. METHODS: Patients with mRCC receiving a first-line targeted therapy were identified from an institutional database encompassing consecutive patients treated between 2009 and 2019. Patient demographics, clinical characteristics and survival outcomes were recorded. The racial/ethnic groups included for analysis were Caucasian American, Hispanic American, and Asian American. Survival and response outcomes including progression-free survival (PFS), overall survival (OS), objective response rate (ORR) and disease control rate (DCR) were calculated and compared across ethnic groups using Kaplan-Meier method and Chi-square test, respectively. RESULTS: In total, 295 patients were included for analysis. There were 184 (62.4%) Caucasian American patients, 82 (27.8%) Hispanic American patients, and 29 (9.8%) Asian American patients. No statistically significant differences in PFS nor OS were found between groups (PFS: 5.6 vs. 4.7 vs. 4.7 months, respectively) (OS: 32 vs. 31.7 vs. 51.7 months, respectively). No significant difference was found in ORR nor DCR across groups. Univariate cox regression analyses demonstrated no independent effect of race/ethnicity on PFS or OS. CONCLUSIONS: The apparent lack of differences in treatment-related outcomes across racial/ethnic groups is encouraging. However, further validation is required in larger series.

Racial and ethnic differences in survival in contemporary metastatic renal cell carcinoma patients, according to alternative treatment modalities

PURPOSE

To test the association between African-American race and overall mortality (OM) rates in patients with metastatic renal cell carcinoma (mRCC).

METHODS

Within the Surveillance, Epidemiology, and End Results registry (2006-2015), we identified patients with clear cell (ccmRCC) and non-clear cell mRCC (non-ccmRCC). African-Americans, Caucasians, and Hispanics were identified. Stratification was made according to histology and treatments: (1) no treatment, (2) systemic therapy (ST), (3) cytoreductive nephrectomy (CNT), (4) CNT + ST. Kaplan-Meier plots and multivariable Cox regression analyses were used.

RESULTS

Of ccmRCC patients, 410 (7%), 4353 (75%), and 1005 (17%) were African-American, Caucasian, and Hispanic, respectively. Of non-ccmRCC patients, 183 (25%), 479 (65%), and 77 (10%) were African-American, Caucasian, and Hispanic, respectively. In ccmRCC, African-Americans were associated with higher OM rates (HR 1.20; 95% CI 1.05-1.37). Conversely, in non-ccmRCC, African-Americans were associated with lower OM rates (HR 0.75; 95% CI 0.59-0.97).

CONCLUSION

African-American race is associated with prolonged survival in non-ccmRCC, but it is also associated with lower survival rates in ccmRCC. The exception to these observations consisted of patients treated with combination of CNT + ST for either ccmRCC or non-ccmRCC.

Racial/ethnic disparities in renal cell carcinoma: Increased risk of early-onset and variation in histologic subtypes

Background

Racial/ethnic minority groups have a higher burden of renal cell carcinoma (RCC), but RCC among Hispanic Americans (HAs) and American Indians and Alaska Natives (AIs/ANs) are clinically not well characterized. We explored variations in age at diagnosis and frequencies of RCC histologic subtypes across racial/ethnic groups and Hispanic subgroups using National Cancer Database (NCDB) and Arizona Cancer Registry Data.

Methods

Adult RCC cases with known race/ethnicity were included. Logistic regression analysis was performed to estimate odds and 95% confidence interval (CI) of early‐onset (age at diagnosis <50 years) and diagnosis with clear cell RCC (ccRCC) or papillary RCC.

Results

A total of 405 073 RCC cases from NCDB and 9751 cases from ACR were identified and included. In both datasets, patients from racial/ethnic minority groups had a younger age at diagnosis than non‐Hispanic White (NHW) patients. In the NCDB, AIs/ANs had twofold increased odds (OR, 2.21; 95% CI, 1.88‐2.59) of early‐onset RCC compared with NHWs. HAs also had twofold increased odds of early‐onset RCC (OR, 2.14; 95% CI, 1.79‐2.55) in the ACR. In NCDB, ccRCC was more prevalent in AIs (86.3%) and Mexican Americans (83.5%) than NHWs (72.5%). AIs/ANs had twofold increased odds of diagnosis with ccRCC (OR, 2.18; 95% CI, 1.85‐2.58) in the NCDB, but the association was stronger in the ACR (OR, 2.83; 95% CI, 2.08‐3.85). Similarly, Mexican Americans had significantly increased odds of diagnosis with ccRCC (OR, 2.00; 95% CI, 1.78‐2.23) in the NCDB.

Conclusions

This study reports younger age at diagnosis and higher frequencies of ccRCC histologic subtype in AIs/ANs and Hispanic subgroups. These variations across racial/ethnic groups and Hispanic subgroups may have potential clinical implications.

Ethnic disparities in renal cell carcinoma: An analysis of Hispanic patients in a single-payer healthcare system

OBJECTIVE

To investigate differences between Hispanics and non-Hispanic whites diagnosed with and treated for renal cell carcinoma in an equal access healthcare system.

METHODS

We carried out a retrospective cohort study within the Kaiser Permanente healthcare system using records from renal cell carcinoma cases. Ethnicity was identified as Hispanic or non-Hispanic whites. Patient characteristics, comorbidities, tumor characteristics and treatment were compared. Overall and disease-specific survival was calculated, and a Cox proportion hazard model estimated the association of ethnicity and survival.

RESULTS

A total of 2577 patients (2152 non-Hispanic whites, 425 Hispanic) were evaluated. Hispanics were diagnosed at a younger age (59.6 years vs 65.3 years). Clear cell renal cell carcinoma was more prevalent, whereas papillary renal cell carcinoma was less common among Hispanics. Hispanics had a lower American Joint Committee on Cancer stage (I/II vs III/IV) than non-Hispanic whites (67.4% vs 62.2%). Hispanics were found to have a greater frequency of comorbidities, such as chronic kidney disease and diabetes, but were more likely to receive surgery. The presence of metastases, nodal involvement, increased tumor size, non-surgical management, increasing age and Hispanic ethnicity were independent predictors of worse cancer-specific outcome.

CONCLUSIONS

Within an equal access healthcare system, Hispanics seem to be diagnosed at younger ages, to have greater comorbidities and to present more frequently with clear cell renal cell carcinoma compared with non-Hispanic white patients. Despite lower stage and greater receipt of surgery, Hispanic ethnicity seems to be an independent predictor of mortality. Further work is necessary to confirm these findings.

Leukocyte telomere length and renal cell carcinoma survival in two studies

BACKGROUND

Leukocyte telomere length (LTL) is a potential biomarker of cancer prognosis; however, evidence for renal cell carcinoma (RCC) is inconsistent.

METHODS

We investigated LTL and RCC-specific survival among 684 cases from the US kidney cancer study (USKC) and 241 cases from the prostate, lung, colorectal, and ovarian cancer screening trial (PLCO). Leukocyte telomere length was measured by quantitative polymerase chain reaction, and hazard ratios (HRs) and 95% confidence intervals (CIs) computed using multivariable Cox models.

RESULTS

Short LTL was associated with poorer disease-specific survival in both USKC (lowest vs highest quartile: HR: 2.3, 95% CI: 1.2-4.4; P for trend=0.02) and PLCO (HR: 2.4, 95% CI: 1.0-5.4; P=0.04). Among USKC cases, the association was strongest for stage-I RCC (HR: 5.5, 95% CI: 1.6-19.0; P=0.006).

CONCLUSIONS

Our findings suggest that shorter LTL is an independent marker of poor RCC prognosis, particularly for stage-I disease.

Metastatic renal cell carcinoma: Patterns and predictors of metastases-A contemporary population-based series

OBJECTIVE

To assess the patterns and predictors of metastatic disease in renal cell carcinoma (RCC) at the time of diagnosis in a contemporary series.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for all patients with kidney RCC from 2010 to 2013 (N = 50,815). Distribution and predictors of distant metastases at diagnosis were assessed. Multivariate logistic regression hazard analyses were performed to determine covariates associated with the likelihood of having metastases at diagnosis, whereas competing risks regression analysis was used to assess predictors of cancer-specific mortality (CSM) in patients with metastatic disease.

RESULTS

Lung (7.73%) and bone (5.17%) metastases were the most common. The strongest predictors of metastatic disease were disease-specific factors, such as clinical T-stage (cT4 vs. cT1; odds ratio = 43.08; P<0.01) and higher Fuhrman grade (FG4 vs. FG1; odds ratio = 5.09; P<0.01). Papillary RCC and chromophobe RCC were associated with localized disease at the time of diagnosis. For CSM, the presence of brain and liver metastases were associated with worse CSM than lung or bone metastases. Although patient factors did not contribute to the presence of metastases at diagnosis, lower socioeconomic status and being widowed/divorced predicted worse CSM.

CONCLUSION

Understanding the distribution of distant metastases and associated CSM is important to counseling patients with newly diagnosed metastatic RCC. Although pathologic factors drive the presence of metastases at diagnosis, health care deficits in treatment remain.

Epigenetic basis of cancer health disparities: Looking beyond genetic differences

Despite efforts at various levels, racial health disparities still exist in cancer patients. These inequalities in incidence and/or clinical outcome can only be explained by a multitude of factors, with genetic basis being one of them. Several investigations have provided convincing evidence to support epigenetic regulation of cancer-associated genes, which results in the differential transcriptome and proteome, and may be linked to a pre-disposition of individuals of certain race/ethnicity to early or more aggressive cancers. Recent technological advancements and the ability to quickly analyze whole genome have aided in these efforts, and owing to their relatively easy detection, methylation events are much well-characterized, than the acetylation events, across human populations. The early trend of investigating a pre-determined set of genes for differential epigenetic regulation is paving way for more unbiased screening. This review summarizes our current understanding of the epigenetic events that have been tied to the racial differences in cancer incidence and mortality. A better understanding of the epigenetics of racial diversity holds promise for the design and execution of novel strategies targeting the human epigenome for reducing the disparity gaps.

Update on active surveillance for clinical T1 renal tumors

PURPOSE OF REVIEW

The purpose is to discuss current data on the utilization and outcomes of active surveillance for T1a renal masses. Specifically, to address which patients are optimal for active surveillance and how their outcomes differ from those undergoing immediate treatment.

RECENT FINDINGS

Although nephron sparing surgery is the standard of care for small renal masses (SRMs), active surveillance is becoming a more popular intervention given the results of prospective studies revealing active surveillance to be safe and have excellent cancer-specific survival with intermediate follow-up. Older and sicker patients have competing risk of death from other causes when diagnosed with a SRM.

SUMMARY

Active surveillance is becoming a more popular treatment modality for SRMs given the increasing number of incidental diagnoses and better understanding of their often indolent course. Active surveillance with delayed intervention is a well-tolerated treatment modality and appears to have the most benefit for those patients that are older with more comorbidities.

Racial disparities in renal cell carcinoma: a single-payer healthcare experience

Significant racial disparities in survival for renal cell carcinoma (RCC) exist between white and black patients. Differences in access to care and comorbidities are possible contributors. To investigate if racial disparities persist when controlling for access to care, we analyzed data from a single-payer healthcare system. As part of a case-control study within the Kaiser Permanente Northern California system, pathologic and clinical records were obtained for RCC cases (2152 white, 293 black) diagnosed from 1998 to 2008. Patient demographics, comorbidities, tumor characteristics, and treatment status were compared. Overall survival and disease-specific survival (DSS) were calculated by the Kaplan-Meier method. A Cox proportion hazards model estimated the independent associations of race, comorbidity, and clinicopathologic variables with DSS. We found that compared to white patients, black patients were diagnosed at a younger age (median 62 vs. 66 years, P < 0.001), were more likely to have papillary RCC (15% vs. 5.2%, P < 0.001), and had similar rates of surgical treatment (78.8% vs. 77.9%, P = 0.764). On multivariate analysis, advanced American Joint Committee on Cancer (AJCC) stage, lack of surgical treatment, larger tumor size, and higher grade were predictors of worse DSS. Race was not an independent predictor of survival. Therefore, we conclude that within a single healthcare system, differences in characteristics of black and white patients with RCC persist; black patients had different comorbidities, were younger, and had decreased tumor stage. However, unlike other series, race was not an independent predictor of DSS, suggesting that survival differences in large registries may result from barriers to healthcare access and/or comorbidity rather than disease biology.

Racial disparities in overall survival among renal cell carcinoma patients with young age and small tumors

We examined the overall survival of a population‐based cohort of black and white patients with renal cell carcinoma (RCC) to better understand the paradox of poorer RCC survival despite more frequent diagnosis at lower stage among blacks. Renal cell carcinoma patients (699 white, 252 black) diagnosed between 2002 and 2007 in metropolitan Detroit were followed for vital status in the Detroit Surveillance, Epidemiology and End Results (SEER) registry. Hazard ratios (HR) of death for black versus white race and 95% confidence intervals (CIs) were calculated using Cox proportional hazard models stratified by demographic and prognostic factors, and in models successively adjusted for clinical factors, comorbidities, and socioeconomic factors. Mean follow‐up time was 88.4 months for white patients and 89.6 months for black patients (P = 0.49), with 202 white deaths and 89 black deaths (P = 0.06). While black race was weakly associated with poorer overall survival (P = 0.053), black patients <65 years at diagnosis or with tumors <4 cm in size had significantly poorer survival than their white counterparts (HR = 1.46, 95% CI 1.06–2.01 and HR = 2.15, 95% CI 1.51–3.06, respectively). The racial disparities within these two subgroups were minimally affected by adjustment for clinical/treatment factors (HR = 1.49, 95% CI 1.01–2.19 and HR = 1.95, 95% CI 1.27–2.99), but were substantially reduced when renal‐relevant comorbidities were added (HR = 1.30, 95% CI 0.89–1.91 and HR = 1.76, 95% CI 1.16–2.66). After further adjustment for socioeconomic factors, the survival disparities were essentially null (HR = 1.14, 95% CI 0.71–1.85 and HR = 1.15, 95% CI 0.67–1.98). In this population‐based sample of RCC patients, younger black patients and those with small tumors had poorer overall survival than whites. The disparity was explained primarily by racial differences in renal‐relevant comorbidities, particularly chronic renal failure, and socioeconomic deprivation. Future research should focus on younger patients and those with smaller tumors to better understand how these factors may contribute to the survival disparity.