The Prognostic Impact of Comorbidities on Renal Cancer, 1995 to 2006: A Danish Population Based Study

Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis

To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.

Impact of comorbidity on renal cell carcinoma prognosis: a nationwide cohort study

BACKGROUND

Presence of comorbid diseases at time of cancer diagnosis may affect prognosis. We evaluated the impact of comorbidity on survival of patients diagnosed with renal cell carcinoma (RCC), overall and among younger (<70 years) and older (≥70 years) patients.

METHODS

We established a nationwide register-based cohort of 7894 patients aged ≥18 years diagnosed with RCC in Denmark between 2006 and 2017. We computed 1- and 5-year overall survival and hazard ratios (HRs) for death according to the Charlson Comorbidity Index (CCI) score.

RESULTS

Survival decreased with increasing CCI score despite an overall increase in survival over time. The 5-year survival rate of patients with no comorbidity increased from 57% among those diagnosed in 2006-2008 to 69% among those diagnosed in 2012-2014. During the same periods, the survival rate increased from 46% to 62% among patients with a CCI score of 1-2 and from 39% to 44% for those with a CCI score of ≥3. Patients with CCI scores of 1-2 and ≥3 had higher mortality rates than patients with no registered comorbidity (HR 1.15, 95% CI 1.06-1.24 and HR 1.56, 95% CI 1.40-1.73). Patterns were similar for older and younger patients. Particularly, diagnoses of liver disease (HR 2.09, 95% CI 1.53-2.84 and HR 4.01, 95% CI 2.44-6.56) and dementia (HR 2.16, 95% CI 1.34-3.48) increased mortality.

CONCLUSION

Comorbidity decreased the survival of patients with RCC, irrespective of age, despite an overall increasing survival over time. These results highlight the importance of focusing on comorbidity in this group of patients.

Prediction of post radical nephrectomy complications based on patient comorbidity preoperatively

OBJECTIVES

Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, using standardized systems to grade both comorbidity and severity of postoperative complications.

MATERIALS AND METHODS

Clinicopathological data of 171 patients undergoing open radical nephrectomy for lesions suspected of RCC were prospectively recorded for a period of 3 years. Comorbidity was scored using the Charlson Comorbidity Index (CCI) while postoperative complications were graded according to the Clavien-Dindo system.

RESULTS

Patients were predominantly males (59.1%); their age ranged from 35 to 88 years (mean ± SD: 63.6 ± 11.9 yrs) with 50.8% of them being ≤ 65 yrs. CCI ranged from 0 to 8 with the majority (85.3%) scoring ≤ 2. The procedure was uncomplicated in 57.3% cases; 10 patients suffered major (grade III/IV) complications and 4 patients died within the 40 days postoperative period. CCI correlated with the manifestation of any postoperative complication, Clavien ≥ 1, OR (95% CI): 1.47 (1.09-1.96), p = 0.011 and the occurrence of severe complications, Clavien > 2. OR (95% CI): 1.29 (1.01-1.63), p = 0.038.

CONCLUSIONS

The present prospective study showed that considerable complications occur in patients with major comorbidities. CCI is easily calculated and should be incorporated in preoperative consultation especially in cases of elder patients with severe comorbidity and favorable tumor characteristics where less invasive interventions or even active surveillance could be applied.

Image-guided percutaneous cryoablation of T1b renal cell carcinomas in patients with comorbidities

PURPOSE

To investigate the influence of comorbidities and tumor characteristics on outcomes following percutaneous cryoablation (PCA) of T1b renal cell carcinoma (RCC).

MATERIALS AND METHODS

Age-adjusted Charlson comorbidity index (ACCI); standardized system for quantitating renal tumor size, location, and depth (RENAL nephrometry score [RNS]); and local tumor control and survival were retrospectively investigated in 28 patients who underwent PCA for stage T1b RCC. Risk factors for elevated serum creatinine levels were also investigated.

RESULTS

Complete ablation was obtained in 27 of 28 patients. Two cases of metastasis were observed; one patient died 12 months after PCA. Overall survival at 5 years was 79.1%, with a mean follow-up of 42.0 ± 16.0 months. Local tumor control was not correlated with the ACCI and RNS. Worsening renal function 3 months after PCA was observed in ten patients, and it correlated with the presence of single kidneys (7/28 patients; p = 0.023). Significant worsening of renal function continued until 1 year after PCA (p = 0.013). Having a single kidney was a risk factor for worsened renal function after PCA (odds ratio, 8.00; 95% confidence interval 1.170-54.724).

CONCLUSION

PCA for T1b RCC confers positive local tumor control regardless of comorbidities and tumor characteristics.

Short- and Long-Term Outcome of Chronic Dialyzed Patients Admitted to the ICU and Assessment of Prognosis Factors: Results of a 6-Year Cohort Study

OBJECTIVES

Data about end-stage kidney disease patients admitted to the ICU are scarce, dated, and mostly limited to short-term survival. The aim of this study was to assess the short- and long-term outcome and to determine the prognostic factors for end-stage kidney disease patients admitted to the ICU.

DESIGN

Prospective observational study.

SETTING

Medical ICUs in two university hospitals.

PATIENTS

Consecutive end-stage kidney disease patients admitted in two ICUs between 2012 and 2017.

INTERVENTION

None.

MEASUREMENTS AND MAIN RESULTS

Renal replacement therapy variables, demographic, clinical, and biological data were collected. The requirement of mechanical ventilation and vasopressive drugs were also collected. In-ICU and one-year mortality were estimated and all data were analyzed in order to identify predictive factors of short and long-term mortality. A total of 140 patients were included, representing 1.7% of total admissions over the study period. Septic shock was the main reason for admission mostly of pulmonary origin. Median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score were at 63 and 6.7, respectively. In-ICU, hospital, and 1-year mortality were 41.4%, 46.4%, and 63%, respectively. ICU mortality was significantly higher as compared with ICU control group non-end-stage kidney disease (25% vs 41.4%; p = 0.005). By multivariate analysis, the short-term outcome was significantly associated with nonrenal Sequential Organ Failure Assessment score, and with the requirement of mechanical ventilation or/and vasoconstrictive agents during ICU stay. One-year mortality was associated with increased dialysis duration (> 3 yr) and phosphatemia (> 2.5 mmol/L), with lower albuminemia (< 30 g/L) and nonrenal Sequential Organ Failure Assessment greater than 8.

CONCLUSIONS

End-stage kidney disease patients presented frequently severe complications requiring critical care that induced significant short- and long-term mortality. ICU and hospital mortality depended mainly on the severity of the critical event reflected by Sequential Organ Failure Assessment score and the need of mechanical ventilation and/or catecholamines. One-year mortality was associated with both albuminemia and phosphatemia and with prior duration of chronic dialysis treatment, and with organ failure at ICU admission.

Microbiome within Primary Tumor Tissue from Renal Cell Carcinoma May Be Associated with PD-L1 Expression of the Venous Tumor Thrombus

Objective

To perform a proof of concept microbiome evaluation and PD-L1 expression profiling in clear-cell renal cell carcinoma (cc-RCC) with associated tumor thrombus (TT).

Methods

After IRB approval, six patients underwent radical nephrectomy (RN) with venous tumor thrombectomy (VTT). We collected fresh tissue specimens from normal adjacent, tumor, and thrombus tissues. We utilized RNA sequencing to obtain PD-L1 expression profiles and perform microbiome analysis. Statistical assessment was performed using Student's t-test, chi-square, and spearman rank correlations using SPSS v25.

Results

We noted the tumor thrombus to be mostly devoid of diverse microbiota. A large proportion of Staphylococcus epidermidus was detected and unknown if this is a surgical or postsurgical contaminant; however, it was noted more in the thrombus than other tissues. Microbiome diversity profiles were most abundant in the primary tumor compared to the thrombus or normal adjacent tissue. Differential expression of PD-L1 was examined in the tumor thrombus to the normal background tissue and noted three of the six subjects had a threshold above 2-fold. These three similar subjects had foreign microbiota that are typical residents of the oral microbiome.

Conclusion

Renal tumors have more diverse microbiomes than normal adjacent tissue. Identification of resident oral microbiome profiles in clear-cell renal cancer with tumor thrombus provides a potential biomarker for thrombus response to PD-L1 inhibition.

The association between socioeconomic position and tumour size, grade, stage, and mortality in Danish sarcoma patients - A national, observational study from 2000 to 2013

Background: Survival in sarcoma patients depends on a range of prognostic factors. An association between cancer survival and socioeconomic position is known for several other cancers. We therefore examined the relations between three socioeconomic factors and risk of presenting with known tumour related prognostic factors, and the overall mortality of the different socioeconomic and prognostic factors in 1919 patients diagnosed with sarcoma in Denmark 2000-2013.Material and methods: Patients with sarcoma in extremities or trunk wall aged 30 years or more at diagnosis were identified in the Danish Sarcoma Registry and linked on an individual level to Danish national registries. We obtained data on educational level, disposable income and cohabitation status. Odds ratios (ORs) were estimated for the association between the socioeconomic factors and grade, stage and tumour size. Hazard ratios (HRs) were estimated using Cox proportional hazard models.Results: In adjusted analyses, educational level, income and cohabitation status were not associated with high grade or dissiminated stage at time of diagnosis. However, living alone was statistically significantly associated with having a large soft tissue sarcoma (≥5 cm) at time of diagnosis (OR 1.51; CI1.12-2.03). The overall mortality was statistically significantly increased in the group of patients with ≤10 years of education (HR 1.27; CI 1.02-1.57), in patients with the 20% lowest income (HR 1.30; CI 1.00-1.67) and nearly in patients living alone (HR 1.16; CI 0.99-1.36).Conclusion: In this nationwide, multicentre, population-based study, soft tissue sarcoma patients living alone had greater risk of having a large tumour at time of diagnosis. Soft tissue and bone sarcoma patients with a short education, low income, or living alone, had a higher mortality. This might indicate that the social differences in mortality might be related to treatment aspects and the biology of the disease rather that the diagnostic process.

Diabetes and kidney cancer survival in patients undergoing nephrectomy: A Canadian multi-center, propensity score analysis

INTRODUCTION

Diabetes has been associated with worse survival outcomes in various malignancies; however, there are conflicting data in kidney cancer. Determining whether diabetes is associated with survival in kidney cancer may help guide treatment in a comorbid patient population.

METHODS

We used the Canadian Kidney Cancer information system database to identify patients undergoing partial or radical nephrectomy between 1989 and 2017 for localized renal cell carcinoma at 16 institutions across Canada. We derived inverse probability of treatment weights (IPTW) from a propensity score model based on various clinical, surgical, and pathological characteristics. We used Cox proportional hazard models to evaluate the association between diabetes and cancer-specific and overall survival, in the sample weighted by the IPTW.

RESULTS

4828 patients met inclusion criteria, of whom 948 (19.6%) were diabetic. Median follow-up in those without death was 26.6 months (interquartile range 9.7-53.8). Among the entire cohort, 901 deaths were from any cause, and 299 deaths from kidney cancer. Before propensity score methods, diabetics were older, more likely to have comorbidities and clear cell histopathology. After propensity score adjustment, all characteristics were balanced between groups (standardized difference <0.10). IPTW-adjusted Cox proportional hazard models demonstrated no significant association between diabetes and cancer-specific (hazard ratio 1.13, 95% confidence interval 0.78-1.62), or overall survival (hazard ratio 1.14, 95% confidence interval 0.94-1.38).

CONCLUSIONS

Our multi-centre study found that diabetes and nondiabetics have similar survival following nephrectomy for kidney cancer.

Immunogenic Heterogeneity of Renal Cell Carcinoma With Venous Tumor Thrombus

OBJECTIVE

To perform immune-cell enumeration and programmed death-ligand 1 (PD-L1) expression in clear cell renal cell carcinoma (cc-RCC) with tumor thrombus (TT) to guide therapeutic decisions.

METHODS

After obtaining IRB approval and surgical consent, 6 patients underwent radical nephrectomy with venous tumor thrombectomy. We utilized RNA Sequencing to obtain RNAseq expression profiles. Computational calculation and enumeration of immune cells were performed using CIBERSORT, xCell, and ingenuity pathway analysis software. Statistical assessment was conducted using a t test, chi-square, ANOVA and Spearman rank correlations using SPSS v21.

RESULTS

We observed a higher proportion of M1 macrophages in the primary tumor and tumor thrombus, while we noted no difference in M2 macrophages despite M2 representing a high number in thrombus samples. (ANOVA, P = .032, and P = .89, respectively). Validation with xCell and ingenuity pathway analysis analysis showed a high involvement of macrophages. We observed a higher number of M1 macrophages (CIBERSORT mean 0.11 vs 0.03, P < 0.01) and (nonactivated) resting Natural Killer (NK) cells (0.077 vs 0.017, P = .02) associated PD-L1 high expression of the primary tumor. PDL1 expression was variable without differences in tumor stage, level, or immune cell detection. We observed an inverse correlation of mean platelet volume with PD-L1 expression within the primary tumor (Spearman, -0.89, P = 02) and the TT (Spearman, -0.77, P = 0.07).

CONCLUSION

Renal tumor thrombus has higher levels of M1 macrophages that could be utilized as additional targets for future drug development. The PD-L1 expression on clear cell RCC biopsy may not represent its corresponding TT. Future studies are needed to confirm mean platelet volume as a potential blood-based biomarker for PD-L1 expression in RCC.

The natural history of large renal masses followed on observation

PURPOSE

The safety and feasibility of active surveillance in comorbid patients with renal masses ≥4.0cm is uncertain. The aim of this study is to describe our institutional experience with the observation of large renal masses.

MATERIALS AND METHODS

One hundred patients were identified with renal masses ≥ 4.0cm that were followed on observation for at least 6 months without surgical intervention between 1994 and 2016. Linear regression was conducted to determine predictors for renal mass growth and competing risk methods were used to estimate the probability of progression in the setting of death from other causes.

RESULTS

Median age at diagnosis was 73 years and 73% of patients had a Charlson Comorbidity index ≥ 4. At presentation, the median mass size was 4.9cm. The median growth rate was 0.4cm/y and there were no significant predictors of growth. Surveillance was discontinued in 34 patients who underwent delayed intervention. Median follow up for metastasis-free survivors was 4 years. In total, 10 patients developed metastatic disease, 3 died from kidney cancer and 30 patients died from other causes. The 5-year probability of other cause mortality was 22% (95% CI: 14%-32%) compared to 6% (95% CI: 2%-13%) for metastatic progression of kidney cancer.

CONCLUSION

In highly comorbid patients, the observation of large renal masses has low likelihood for metastatic progression relative to the risk of nonkidney cancer related death. This data supports the use of surveillance as an acceptable strategy for highly selected patients with competing risks from other serious illnesses.

The impact of comorbidity on mortality in Danish sarcoma patients from 2000-2013: A nationwide population-based multicentre study

INTRODUCTION

Sarcoma is a rare type of cancer. The incidence increases with age and elderly patients may have comorbidity that affects the prognosis. The aim of this study was to describe the type and prevalence of comorbidity in a nationwide population-based study in Denmark from 2000-2013 and to analyse the impact of the different comorbidities on mortality.

MATERIAL AND METHODS

The Danish Sarcoma Registry is a national clinical database containing all patients with sarcoma in the extremities or trunk wall from 2000 and onwards. By linking data to other registries, we were able to get patient information on an individual level including date and cause of death as well as the comorbidity type up to 10 years prior to the sarcoma diagnosis. Based on diseases in the Charlson Comorbidity Index, we pooled the patients into six categories: no comorbidity, cardiopulmonary disease, gastrointestinal disease, neurovascular disease, malignant neoplasms, and miscellaneous (diabetes, renal and connective tissue diseases). 2167 patients were included.

RESULTS

The prevalence of comorbidity was 20%. For patients with localized disease, comorbidity increased the disease-specific mortality significantly (HR 1.70 (95% CI 1.36-2.13)). For patients with metastatic disease at the time of diagnosis, comorbidity did not affect the disease-specific mortality (HR 1.05 (95% CI 0.78-1.42)). The presence of another cancer diagnosis within 10 years prior to the sarcoma diagnosis was the only significant independent prognostic factor of disease-specific mortality with an increase of 66% in mortality rate compared to patients with no comorbidity (HR 1,66 (95% CI 1.22-2.25)).

CONCLUSION

Comorbidity is a strong independent prognostic factor of mortality in patients with localized disease. This study emphasizes the need for optimizing the general health of comorbid patients in order to achieve a survival benefit from treatment of patients with localized disease, as this is potentially modifiable.

Reproducibility, reliability and validity of population-based administrative health data for the assessment of cancer non-related comorbidities

BACKGROUND

Patients with comorbidities do not receive optimal treatment for their cancer, leading to lower cancer survival. Information on individual comorbidities is not straightforward to derive from population-based administrative health datasets. We described the development of a reproducible algorithm to extract the individual Charlson index comorbidities from such data. We illustrated the algorithm with 1,789 laryngeal cancer patients diagnosed in England in 2013. We aimed to clearly set out and advocate the time-related assumptions specified in the algorithm by providing empirical evidence for them.

METHODS

Comorbidities were assessed from hospital records in the ten years preceding cancer diagnosis and internal reliability of the hospital records was checked. Data were right-truncated 6 or 12 months prior to cancer diagnosis to avoid inclusion of potentially cancer-related comorbidities. We tested for collider bias using Cox regression.

RESULTS

Our administrative data showed weak to moderate internal reliability to identify comorbidities (ICC ranging between 0.1 and 0.6) but a notably high external validity (86.3%). We showed a reverse protective effect of non-cancer related Chronic Obstructive Pulmonary Disease (COPD) when the effect is split into cancer and non-cancer related COPD (Age-adjusted HR: 0.95, 95% CI:0.7-1.28 for non-cancer related comorbidities). Furthermore, we showed that a window of 6 years before diagnosis is an optimal period for the assessment of comorbidities.

CONCLUSION

To formulate a robust approach for assessing common comorbidities, it is important that assumptions made are explicitly stated and empirically proven. We provide a transparent and consistent approach useful to researchers looking to assess comorbidities for cancer patients using administrative health data.

Management of Small Renal Masses: American Society of Clinical Oncology Clinical Practice Guideline

Purpose To provide recommendations for the management options for patients with small renal masses (SRMs). Methods By using a literature search and prospectively defined study selection, we sought systematic reviews, meta-analyses, randomized clinical trials, prospective comparative observational studies, and retrospective studies published from 2000 through 2015. Outcomes included recurrence-free survival, disease-specific survival, and overall survival. Results Eighty-three studies, including 20 systematic reviews and 63 primary studies, met the eligibility criteria and form the evidentiary basis for the guideline recommendations. Recommendations On the basis of tumor-specific findings and competing risks of mortality, all patients with an SRM should be considered for a biopsy when the results may alter management. Active surveillance should be an initial management option for patients who have significant comorbidities and limited life expectancy. Partial nephrectomy (PN) for SRMs is the standard treatment that should be offered to all patients for whom an intervention is indicated and who possess a tumor that is amenable to this approach. Percutaneous thermal ablation should be considered an option if complete ablation can reliably be achieved. Radical nephrectomy for SRMs should only be reserved for patients who possess a tumor of significant complexity that is not amenable to PN or for whom PN may result in unacceptable morbidity even when performed at centers with expertise. Referral to a nephrologist should be considered if chronic kidney disease (estimated glomerular filtration rate < 45 mL/min/1.73 m²) or progressive chronic kidney disease occurs after treatment, especially if associated with proteinuria.

Radiologic indicators prior to renal cell cancer thrombectomy: Implications for vascular reconstruction and mortality

Background:

Renal cancer may invade the inferior vena cava (IVC) creating more complex surgical intervention. We investigate radiologic findings that may predict vascular reconstruction prior to surgery and future renal cancer-specific mortality.

Materials and Methods:

Radiologic findings included Mayo Clinic risk factors for vascular reconstruction: Right-sided tumor, anteroposterior diameter of the IVC at the ostium of the renal vein ≥24.0 mm, and radiologic identification of complete occlusion of the IVC. Additional factors included thrombus in the lumen of the hepatic veins and metastasis. Along with other demographic factors, analysis included Chi-squared analysis for vascular reconstruction and logistic regression for mortality. A Kaplan–Meier curve was created for the most significant radiologic factor.

Results:

Thirty-seven patients underwent IVC tumor thrombectomy at two institutions from April 2007 to February 2015. We found that Mayo risk factors of 0, 1, 2, and 3 and the proportions of vascular reconstruction of 0%, 0%, 12.5%, and 13.6%, respectively (P = 0.788). Hepatic vein involvement was the most significant determinate of renal cell carcinoma-specific mortality in multivariable analysis, controlling for the size of IVC at the hepatic veins, pulmonary metastasis, and Fuhrman grade (P = 0.02, Log-rank P = 0.002).

Conclusion:

Mayo risk factors did not predict vascular reconstruction in our small cohort of Level II–Level IV IVC thrombus undergoing IVC thrombectomy. Tumor thrombus traveling into the lumen of the hepatic veins was a significant risk factor for accelerated mortality.

Active Surveillance for Small Renal Masses: A Review of the Aims and Preliminary Results of the DISSRM Registry

Active surveillance is an increasingly accepted treatment modality for select patients with small renal masses. The DISSRM (delayed intervention and surveillance for small renal masses) registry is a multi-institutional, prospectively collected data repository which includes patients who select active surveillance for their small renal masses, as well as others who select immediate intervention. Preliminary results from the registry suggest oncological equivalence of active surveillance and surgical modalities in the intermediate term. Additionally, the registry provides the first published data regarding trends in renal function among patients undergoing active surveillance. On average, these patients experience a decline in renal function, and their renal functional outcomes are superior to those of patients undergoing radical nephrectomy, but do not significantly differ from those of patients undergoing partial nephrectomy.

Hypertension: a cross-sectional study of the role of multimorbidity in blood pressure control

BACKGROUND

Hypertension is the most prevalent cardiovascular long-term condition in the UK and is associated with a high rate of multimorbidity (MM). Multimorbidity increases with age, ethnicity and social deprivation. Previous studies have yielded conflicting findings about the relationship between MM and blood pressure (BP) control. Our aim was to investigate the relationship between multimorbidity and systolic blood pressure (SBP) in patients with hypertension.

METHODS

A cross-sectional analysis of anonymised primary care data was performed for a total of 299,180 adult patients of whom 31,676 (10.6 %) had a diagnosis of hypertension. We compared mean SBP in patients with hypertension alone and those with one or more co-morbidities and analysed the effect of type of comorbidity on SBP. We constructed a regression model to identify the determinants of SBP control.

RESULTS

The strongest predictor of mean SBP was the number of comorbidities, β -0.13 (p < 0.05). Other predictors included Afro-Caribbean ethnicity, β 0.05 (p < 0.05), South Asian ethnicity, β -0.03 (p < 0.05), age, β 0.05 (p < 0.05), male gender, β 0.05 (p < 0.05) and number of hypotensive drugs β 0.06 (p < 0.05). SBP was lower by a mean of 2.03 mmHg (-2.22, -1.85) for each additional comorbidity and was lower in MM regardless of the type of morbidity.

CONCLUSION

Hypertensive patients with MM had lower SBP than those with hypertension alone; the greater the number of MM, the lower the SBP. We found no evidence that BP control was related to BP targets, medication category or specific co-morbidity. Further research is needed to determine whether consultation rate, "white-coat hypertension" or medication adherence influence BP control in MM.

Effect of psoriasis severity on hypertension control: a population-based study in the United Kingdom

IMPORTANCE

Hypertension is prevalent among patients with psoriasis. The effect of psoriasis and its severity on hypertension control is unknown.

OBJECTIVE

To determine the association between uncontrolled blood pressure and psoriasis, both overall and according to objectively measured psoriasis severity, among patients with diagnosed hypertension.

DESIGN, SETTING, AND PARTICIPANTS

Population-based cross-sectional study nested in a prospective cohort drawn from The Health Improvement Network (THIN), an electronic medical records database broadly representative of the general population in the United Kingdom. The study population included a random sample of patients with psoriasis (n = 1322) between the ages of 25 and 64 years in THIN who were included in the Incident Health Outcomes and Psoriasis Events prospective cohort and their age- and practice-matched controls without psoriasis (n = 11,977). All included patients had a diagnosis of hypertension; their psoriasis diagnosis was confirmed and disease severity was classified by their general practitioners.

MAIN OUTCOMES AND MEASURES

Uncontrolled hypertension was defined as a systolic blood pressure of 140 mm Hg or higher or a diastolic blood pressure of 90 mm Hg or higher based on the blood pressure recorded closest in time to the assessment of psoriasis severity.

RESULTS

There was a significant positive dose-response relationship between uncontrolled hypertension and psoriasis severity as objectively determined by the affected body surface area in both unadjusted and adjusted analyses that controlled for age, sex, body mass index, smoking and alcohol use status, presence of comorbid conditions, and current use of antihypertensive medications and nonsteroidal anti-inflammatory drugs (adjusted odds ratio [aOR], 0.97; 95% CI, 0.82-1.14 for mild psoriasis; aOR, 1.20; 95% CI, 0.99-1.45 for moderate psoriasis; and aOR, 1.48; 95% CI, 1.08-2.04 for severe psoriasis; P = .01 for trend). The likelihood of uncontrolled hypertension among psoriasis overall was also increased, although not statistically significantly so (aOR, 1.10; 95% CI, 0.98-1.24).

CONCLUSIONS AND RELEVANCE

Among patients with hypertension, psoriasis was associated with a greater likelihood of uncontrolled hypertension in a dose-dependent manner, with the greatest likelihood observed among those with moderate to severe psoriasis defined by 3% or more of the body surface area affected. Our data suggest a need for more effective blood pressure management, particularly among patients with more severe psoriasis.

Utilizing national patient-register data to control for comorbidity in prognostic studies

Objective

To construct an updated comorbidity index (Patient Register Index [PRI]) using national data collections from Norway and compare its predictive ability of 1-year mortality with the Charlson Comorbidity Index (CCI).

Materials and methods

Data regarding over 1.11 million patients registered in the Norwegian Patient Register in 2010 and 2011 were used to construct the PRI. The PRI was evaluated by comparing its model fit and discrimination with the CCI.

Results

Compared with the CCI, the PRI weights decreased for six, increased for four, and were unchanged for seven diseases. When the PRI was added to the model including age and sex, the age effects were reduced by up to 38% for patients older than 50 years. All measures of model fit improved for the PRI model.

Conclusion

Adjustment for comorbidity is especially important for patients 50 years of age or older, and its effect on 1-year mortality is almost comparable to the age effect. The PRI is based on more recent data than the CCI, and is more representative of the general population due to its construction.

Prevalence and prognostic impact of comorbidity in soft tissue sarcoma: a population-based cohort study

BACKGROUND

Comorbidity is an important prognostic factor for survival in other cancers, but the importance in soft tissue sarcoma has not yet been clarified. The aims of this study were to examine the prevalence of comorbidity in soft tissue sarcoma patients, and estimate the impact of comorbidity on overall and disease-specific mortality.

MATERIAL AND METHODS

Overall, 1210 adult patients with soft tissue sarcoma in the extremities or trunk wall were identified through the Aarhus Sarcoma Registry, a validated population-based database. Information on comorbidity was obtained through the National Patient Registry, and a Charlson's Comorbidity score was calculated for each patient. The prevalence of comorbidity was assessed overall, as well as according to age and year of diagnosis. Overall and disease-specific mortality rates according to level of comorbidity were computed. The prognostic value of comorbidity was estimated using crude and adjusted Cox proportional hazard models.

RESULTS

The overall prevalence of comorbidity was 25%. The prevalence increased with increasing age, and patients with comorbidity had a larger proportion of adverse prognostic factors when compared to patients without comorbidity. The five-year disease-specific mortality was 26% (95% CI 24-29) for patients without comorbidity, compared to 33% (95% CI 24-42), 41% (95% CI 32-50), and 44% (95% CI 33-55) for patients with mild, moderate, and severe comorbidity, respectively. After adjusting for age, sex, stage, tumor size, depth, grade, surgical margin, radiotherapy, and chemotherapy, comorbidity was independently associated with an increased overall and disease-specific mortality.

CONCLUSION

Patients with comorbidity had significantly increased overall and disease-specific mortality compared to patients without comorbidity, even when adjusting for important prognostic factors including age.

Thinking beyond surgery in the management of renal cell carcinoma: the risk to die from renal cell carcinoma and competing risks of death

INTRODUCTION

The presentation of renal cell carcinoma (RCC) has changed where it is most commonly identified when asymptomatic and incidental. Contemporary patients with renal tumors are often older in age and may have significant concurrent medical comorbidity, where proceeding with routine surgical treatment may not be of benefit. Traditional clinical assessments have not considered the impact of comorbidity on oncologic outcome, and recent studies have demonstrated the relationship between comorbidity and patient survival. We review the existing data examining the significance of medical comorbidity on RCC management and outcomes.

MATERIALS AND METHODS

The existing literature on this topic is reviewed, and validated measures of comorbidity are described. The available studies examining the relationship between comorbidity and RCC are summarized.

RESULTS AND DISCUSSION

The article reviews the growing body of literature supporting the importance of assessment of patient comorbidity, and we highlight novel prognostic instruments that can estimate the likelihood of several different patient outcomes following RCC treatment, and these nomograms can be accessed via a web-based portal ( www.cancernomograms.com ) to assist in patient education and clinical decision making.

Comorbidity in adult bone sarcoma patients: a population-based cohort study

Background. Comorbidity is an important prognostic factor for survival in different cancers; however, neither the prevalence nor the impact of comorbidity has been investigated in bone sarcoma. Methods. All adult bone sarcoma patients from western Denmark treated at the Aarhus Sarcoma Centre in the period from 1979 to 2008 were identified through a validated population-based database. Charlson Comorbidity Index scores were computed, using discharge diagnoses from the Danish National Patient Registry. Survival was assessed as overall and disease-specific mortality. The impact of comorbidity was examined as rates according to the level of comorbidity as well as uni- and multivariately using proportional hazard models. Results. A total of 453 patients were identified. The overall prevalence of comorbidity was 19%. The prevalence increased with age and over the study period. In patients with Ewing/osteosarcoma, comorbidity was not associated with an increased overall or disease-specific mortality. However, patients with bone sarcomas other than Ewing/osteosarcoma had increased overall mortality. Independent prognostic factors for disease-specific survival were age, tumor size, stage at diagnosis, soft tissue involvement, grade, and surgery. Conclusion. The prevalence of comorbidity in bone sarcoma patients is low. Comorbidity impaired survival in patients with non-Ewing/nonosteosarcoma, histology. This emphasizes the importance of not only treating the sarcoma but also comorbidity.

[Renal cell carcinoma: A 12-year retrospective study of epidemiologic, therapeutic and follow-up data]

OBJECTIVE

To describe the evolution of epidemiology and management of renal cell carcinoma and their impact on overall and progression-free survivals.

PATIENTS AND METHODS

We reviewed the files of consecutive patients with renal cell carcinoma in our center between January 2000 and December 2011. Patients with confirmed diagnosis on histology who underwent radical nephrectomy, partial nephrectomy or thermoablation were included. Benign tumors were excluded. Epidemiologic and therapeutic data during the period of study were compared. Overall and progression-free survivals divided in three periods were compared by Kaplan-Meier curves.

RESULTS

Four hundred and forty-nine patients were included with a median age of 60 years old [21; 89], and median follow-up of 39 months. Tumor histology was clear cell carcinoma in 75.9% of cases. During the period of study, patients with ASA score upper than 3 increased from 20.4% to 47.8%, tumor size decreased from 58.4mm to 49.5mm and incidental tumor discovery increased from 59.1% to 71.6%. Nephron-sparing surgery increased from 19.7% to 44%. Overall survival and progression-free survival was not different during this period (P=0.071 and P=0.582).

CONCLUSION

The increase in early incidental discovery of renal cell carcinoma allowed nephron-sparing surgery in spite of patients with more comorbidities, with stable overall and progression-free survivals in our series.

Multimorbidity and blood pressure control in 37 651 hypertensive patients from Danish general practice

Background

Patients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices.

Methods and Results

Using the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men.

Conclusion

In Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

The influence of cardiovascular morbidity on the prognosis in prostate cancer. Experience from a 12-year nationwide Danish population-based cohort study

Background

To determine the impact of preexisting ischemic heart disease (IHD) and stroke on overall survival in prostate cancer patients.

Methods

We conducted a cohort study of patients with incident prostate cancer registered in the Danish Cancer Registry from 1997 through 2008. We identified patients diagnosed with IHD or stroke prior to the date of prostate cancer diagnosis in the Danish National Patient Registry. We constructed Kaplan-Meier curves to analyze time to death and Cox regression was used to estimate hazard ratios (HRs) to compare mortality rates by preexisting IHD or stroke status, adjusting for age, stage, comorbidity, and calendar period.

Results

Of 30,721 prostate cancer patients, 4,276 (14%) had preexisting IHD and 1,331 (4%) preexisting stroke. Crude 1- and 5-year survival rates were 85% and 44% in men without preexisting IHD or stroke, 81% and 36% in men with preexisting IHD, and 78% and 27% in men with preexisting stroke. Adjusted HRs were 1.05 (95% CI 1.00-1.10) for patients with IHD and 1.20 (95% CI 1.12-1.30) for patients with stroke compared with patients without preexisting IHD or stroke.

Conclusions

Preexisting IHD had minimal impact on mortality in prostate cancer patients, whereas overall mortality was 20% higher in prostate cancer patients with preexisting stroke compared to those without IHD or stroke. These results highlight the importance of differentiating between various comorbidities.

Cervical cancer survival for patients referred to a tertiary care center in Kentucky

OBJECTIVES

To identify prognostic factors influencing cervical cancer survival for patients referred to a tertiary care center in Kentucky.

METHODS

A cohort study was performed to assess predictive survival factors of cervical cancer patients referred to the University of Kentucky from January 2001 to May 2010. Eligibility criteria included those at least 18 years-old, cervical cancer history, and no prior malignancy. Descriptive statistics were compiled and univariable and multivariable Cox proportional hazard analysis were performed.

RESULTS

381 patients met entry criteria. 95% were Caucasian (N=347) and 66% (N=243) lived in Appalachian Kentucky. The following covariates showed no evidence of a statistical association with survival: race, body mass index, residence, insurance status, months between last normal cervical cytology and diagnosis, histology, tumor grade, and location of primary radiation treatment. After controlling for identified significant variables, stage of disease was a significant predictor of overall survival, with estimated relative hazards comparing stages II, III, and IV to stage I of 3.09 (95% CI: 1.30, 7.33), 18.11 (95% CI: 7.44, 44.06), and 53.03(95% CI: 18.16, 154.87), respectively. The presence of more than two comorbid risk factors and unemployment was also correlated with overall survival [HR 4.25 (95% CI: 1.00, 18.13); HR 2.64 (95% CI 1.29, 5.42), respectively].

CONCLUSIONS

Residence and location of treatment center are not an important factor in cervical cancer survival when a tertiary cancer center can oversee and coordinate care; however, comorbid risk factors influence survival and further exploration of disease comorbidity related to cervical cancer survival is warranted.

The effect of age on the morbidity of kidney surgery

PURPOSE

Previous reports of the morbidity of renal surgery have been primarily from academic tertiary referral centers and, thus, they may not reflect general clinical practice. We determined the effect of age and comorbidity on in-hospital surgical morbidity for radical and partial nephrectomy on a population level.

MATERIALS AND METHODS

Data were obtained from a Canadian national discharge abstract database. From April 1998 to March 2008 information was available on 20,286 radical and 4,292 partial nephrectomies. Complications were identified using specific ICD-9 and 10 diagnosis and procedure codes. Complication rates were estimated by procedure type and by various explanatory variables, including patient age and Charlson comorbidity score. Multivariate logistic regressions were constructed for radical and partial nephrectomy to determine associations between explanatory variables and complications.

RESULTS

Overall complications developed in 34.1% of radical and 34.3% of partial nephrectomy cases. Patients were more likely to have cardiac, respiratory, vascular and surgical complications after radical nephrectomy while they were more likely to experience genitourinary and nephrectomy specific complications after partial nephrectomy. On multivariate logistic regression after radical and partial nephrectomy complications increased with age and Charlson score. After adjusting for other covariates patients with a Charlson score of greater than 2 were approximately 6 times more likely to experience a complication than patients with a Charlson score of 0 for radical and partial nephrectomy (OR 6.22, 95% CI 5.18-7.48 and OR 5.68, 95% CI 3.72-8.66, respectively).

CONCLUSIONS

In our population based study radical nephrectomy and partial nephrectomy were associated with higher morbidity than previously reported, particularly in the elderly population and in patients with comorbidity.