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Grosso AA, Di Maida F, Tellini R, Viola L, Lambertini L, Valastro F, Mari A, Masieri L, Carini M, Minervini A. 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. Eur J Cancer Care (Engl) 2022; 31:e13666. [PMID: 35869594 PMCID: PMC9787702 DOI: 10.1111/ecc.13666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 04/07/2022] [Accepted: 07/05/2022] [Indexed: 12/30/2022]
Abstract
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.
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Affiliation(s)
- Antonio Andrea Grosso
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Fabrizio Di Maida
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Riccardo Tellini
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Lorenzo Viola
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Luca Lambertini
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Francesca Valastro
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Andrea Mari
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Lorenzo Masieri
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Marco Carini
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
| | - Andrea Minervini
- Department of Experimental and Clinical MedicineUniversity of Florence ‐ Unit of Oncologic Minimally‐Invasive Urology and Andrology, Careggi HospitalFlorenceItaly
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Social Determinants Contribute to Disparities in Test Positivity, Morbidity and Mortality: Data from a Multi-Ethnic Cohort of 1094 GU Cancer Patients Undergoing Assessment for COVID-19. REPORTS 2022. [DOI: 10.3390/reports5030029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: The COVID-19 pandemic exploits existing inequalities in the social determinants of health (SDOH) that influence disease burden and access to healthcare. The role of health behaviours and socioeconomic status in genitourinary (GU) malignancy has also been highlighted. Our aim was to evaluate predictors of patient-level and neighbourhood-level factors contributing to disparities in COVID-19 outcomes in GU cancer patients. Methods: Demographic information and co-morbidities for patients screened for COVID-19 across the Mount Sinai Health System (MSHS) up to 10 June 2020 were included. Descriptive analyses and ensemble feature selection were performed to describe the relationships between these predictors and the outcomes of positive SARS-CoV-2 RT-PCR test, COVID-19-related hospitalisation, intubation and death. Results: Out of 47,379 tested individuals, 1094 had a history of GU cancer diagnosis; of these, 192 tested positive for SARS-CoV-2. Ensemble feature selection identified social determinants including zip code, race/ethnicity, age, smoking status and English as the preferred first language—being the majority of significant predictors for each of this study’s four COVID-19-related outcomes: a positive test, hospitalisation, intubation and death. Patient and neighbourhood level SDOH including zip code/ NYC borough, age, race/ethnicity, smoking status, and English as preferred language are amongst the most significant predictors of these clinically relevant outcomes for COVID-19 patients. Conclusion: Our results highlight the importance of these SDOH and the need to integrate SDOH in patient electronic medical records (EMR) with the goal to identify at-risk groups. This study’s results have implications for COVID-19 research priorities, public health goals, and policy implementations.
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Perspectives on the Role of Biopsy for Management of T1 Renal Masses: Survey Results from Two Regional Quality Improvement Collaboratives. Urology 2022; 165:206-211. [DOI: 10.1016/j.urology.2022.01.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/22/2022]
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Patel AK, Rogers CG, Johnson A, Noyes SL, Qi J, Miller D, Shervish E, Stockton B, Lane BR. Initial Observation of a Large Proportion of Patients Presenting with Clinical Stage T1 Renal Masses: Results from the MUSIC-KIDNEY Statewide Collaborative. EUR UROL SUPPL 2021; 23:13-19. [PMID: 34337485 PMCID: PMC8317780 DOI: 10.1016/j.euros.2020.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND While surgical excision remains the principal management strategy for clinical T1 renal masses (cT1RMs), the rates of noninterventional approaches are not well known. Most single-institution and population-based series suggest rates below 10%. OBJECTIVE To evaluate the use of observation for newly diagnosed cT1RM patients in academic and community-based practices across a statewide collaborative. DESIGN SETTING AND PARTICIPANTS The Michigan Urological Surgery Improvement Collaborative-Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) commenced data collection in September 2017 by recording clinical, radiographic, pathologic, and short-term follow-up data for cT1RM patients at 13 diverse practices. Patients with complete data were assessed at >90 d after initial evaluation as to whether observation or treatment was performed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Relationships with outcomes were analyzed using multivariable logistic regression, chi-square test, and Wilcoxon rank-sum test. RESULTS AND LIMITATIONS Out of 965 patients, observation was employed in 48% (n = 459), with practice-level rates ranging from 0% to 68%. Patients managed with observation (vs treatment) were significantly older (71.2 vs 62.8 yr, p < 0.0001) and had smaller tumors (2.3 vs 3.4 cm, p < 0.0001). Observation was used for 53.5% of cT1a renal masses, for 29.9% of cT1b renal masses, and for 42.5%, 53.7%, and 63.9% of radiographically solid, Bosniak III-IV cystic, and indeterminate cT1RMs, respectively. Factors significantly associated with observation in multivariable analysis included lesion type (Bosniak III-IV vs solid, p = 0.017), tumor stage (cT1a vs cT1b, p < 0.001), and higher age (p < 0.001). A short duration of follow-up limits the assessment of longer-term patient management. CONCLUSIONS Noninterventional management of cT1RMs is common across the MUSIC-KIDNEY collaborative, with wide variability across practices. Factors associated with observation were advanced age, smaller tumor size, and cystic tumor type. Durability of the initial decision for observation (delayed intervention vs active surveillance vs less active surveillance) will be a focus of subsequent study. PATIENT SUMMARY The Michigan Urological Surgery Improvement Collaborative: Kidney mass: Identifying and Defining Necessary Evaluation and therapY (MUSIC-KIDNEY) quality improvement collaborative assessed the current utilization of initial observation of a renal mass ≤7 cm across a diverse group of urology practices and found it to be used in 48% of patients. We found that the factors predicting observation were advanced age, smaller tumor size, and cystic tumor type.
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Affiliation(s)
| | | | - Anna Johnson
- Department of Urology, Michigan Medicine, Ann Arbor, MI, USA
| | | | - Ji Qi
- Department of Urology, Michigan Medicine, Ann Arbor, MI, USA
| | - David Miller
- Department of Urology, Michigan Medicine, Ann Arbor, MI, USA
| | | | | | - Brian R. Lane
- Spectrum Health Hospital System, Grand Rapids, MI, USA
- Michigan State University College of Human Medicine, Grand Rapids, MI, USA
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Patel DN, Ghali F, Meagher MF, Javier-Desloges J, Patel SH, Soliman S, Hakimi K, Yuan J, Murphy J, Derweesh IH. Utilization of renal mass biopsy in patients with localized renal cell carcinoma: A population-based study utilizing the National Cancer Database. Urol Oncol 2020; 39:79.e1-79.e8. [PMID: 33160847 DOI: 10.1016/j.urolonc.2020.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/02/2020] [Accepted: 10/19/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate trends and factors predicting use of renal mass biopsy (RMB) for localized Renal Cell Carcinoma in the United States (US) in the context of current guidelines recommendations. METHODS We queried the National Cancer Database for cT1-cT3N0M0 Renal Cell Carcinoma diagnosed between 2004 and 2015. Temporal trends of RMB were characterized based on tumor size, treatment (partial nephrectomy [PN], radical nephrectomy [RN], ablation, and no treatment), age and Charlson Comorbidity Index with slopes compared using analysis of variance. Multivariable analysis was used to determine factors associated with use of RMB. RESULTS Of 338,252 patients analyzed, 11.9% (40,276) underwent RMB. Use of RMB increased throughout the study period from 1,586 (7.6%) in 2004 to 5,629 (16.2%) in 2015 (P < 0.001). Use of RMB increased greatest for ablation (27 to 63%, P < 0.001) and tumors 2-4 cm (9 to 20%, P < 0.001). Multivariable analysis showed year of diagnosis (OR = 1.06; P < 0.001), higher education (OR = 1.09; P < 0.001) and insured status (OR = 1.23; P < 0.001) were associated with increased RMB. Compared to tumors ≤2 cm, tumors 2.1-4 cm (OR = 1.36; P=<0.001), 4.1-7 cm (OR = 1.18; P <0.001) and >7 cm (OR = 1.05; P = 0.03) were associated with higher rates of RMB. Compared to RN, PN was not associated with increased RMB (OR = 1.00; P = 0.92), while ablation (OR = 10.90; P < 0.001) and no surgical treatment (OR = 4.83; P < 0.001) were. CONCLUSION RMB utilization increased overall, with largest increase associated with ablation. Nonetheless, only two-thirds of patients underwent RMB with ablation, suggesting persistent underutilization. Rates of RMB for tumors ≤2 cm and in those undergoing no treatment increased less, suggesting less utilization for surveillance. However, rates for tumors >2-4 cm increased more, suggesting selective utilization of RMB to guide decision-making and risk stratification in small renal masses.
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Affiliation(s)
- Devin N Patel
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | - Fady Ghali
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | | | | | - Sunil H Patel
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | - Shady Soliman
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | - Kevin Hakimi
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | - Julia Yuan
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA
| | - James Murphy
- Department of Radiation Oncology, UC San Diego School of Medicine, La Jolla, CA
| | - Ithaar H Derweesh
- Department of Urology, UC San Diego School of Medicine, La Jolla, CA.
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Ozambela M, Wang Y, Leow JJ, Silverman SG, Chung BI, Chang SL. Contemporary trends in percutaneous renal mass biopsy utilization in the United States. Urol Oncol 2020; 38:835-843. [PMID: 32912815 DOI: 10.1016/j.urolonc.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 07/11/2020] [Accepted: 07/17/2020] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Patients with a renal mass traditionally proceed directly to surgery without a preoperative tissue diagnosis confirming malignancy. Many surgically treated renal masses represent benign tumors or indolent malignancies on final pathology. This has led to a growing body of literature supporting an expanded role for percutaneous renal mass biopsy (RMB). This study aims to characterize national trends in RMB utilization. METHODS Patients undergoing renal biopsy during a 12-year period (2006-2017) in the Premier Hospital Database were captured using International Classification of Diseases, Ninth Revision and Tenth Revision codes. We restricted our analysis to patients with a concurrent diagnosis of a renal mass. We determined utilization rate, subsequent interventions within 90 days of biopsy, predictors of RMB, and 30-day RMB complication rates. We applied sampling weights and adjusted for hospital clustering to achieve a nationally representative analysis. RESULTS Among 115,511 patients who met the inclusion criteria, the annual number of RMB rose from 7,196 in 2006 to 11,528 in 2017; during this period, more than 3 times as many patients proceeded directly to surgery without a prior RMB. After RMB, 85,848 (74.32%) patients were not treated within 90 days. Of those treated, thermal ablation was more common than surgery (17,269 vs. 12,394). Trend analysis showed that patients with metastatic disease represented a decreasing proportion of patients receiving RMB (27.0%-21.8%; P < 0.001). Compared to patients who proceeded directly to surgery, RMB was more commonly performed in patients in the highest age group (80 years and older, 15.9% vs. 9.2%), unmarried (50% vs. 45.9%), with more medical comorbidities (Charlson comorbidity index ≥4, 30.9% vs. 17.4%), or with metastatic disease (24.5% vs. 10.4%). Multivariable regression analysis determined the primary predictor of RMB was the presence of metastatic disease. Hematuria was the most common complication present in 5.18% of patients followed by pneumothorax in 1.75%. All other complications were rare (<0.4%). CONCLUSION Although there has been progressive adoption of RMB for the management of renal masses in the United States, utilization remains relatively limited and differentially employed across the population based on both clinical and nonclinical patient factors. More research is needed to understand which factors are considered when determining whether to utilize RMB in the evaluation of a renal mass.
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Affiliation(s)
- Manuel Ozambela
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ye Wang
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey J Leow
- Department of Urology, Tan Tock Seng Hospital, Singapore
| | - Stuart G Silverman
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Benjamin I Chung
- Department of Urology, Stanford University Medical Center, Stanford, CA
| | - Steven L Chang
- Division of Urology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
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Active Surveillance of Small Renal Masses. Urology 2019; 123:157-166. [DOI: 10.1016/j.urology.2018.09.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 09/10/2018] [Accepted: 09/18/2018] [Indexed: 01/12/2023]
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Patient and provider experiences with active surveillance: A scoping review. PLoS One 2018; 13:e0192097. [PMID: 29401514 PMCID: PMC5798833 DOI: 10.1371/journal.pone.0192097] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/23/2017] [Indexed: 01/03/2023] Open
Abstract
Objective Active surveillance (AS) represents a fundamental shift in managing select cancer patients that initiates treatment only upon disease progression to avoid overtreatment. Given uncertain outcomes, patient engagement could support decision-making about AS. Little is known about how to optimize patient engagement for AS decision-making. This scoping review aimed to characterize research on patient and provider communication about AS, and associated determinants and outcomes. Methods MEDLINE, EMBASE, CINAHL, and The Cochrane Library were searched from 2006 to October 2016. English language studies that evaluated cancer patient or provider AS views, experiences or behavioural interventions were eligible. Screening and data extraction were done in duplicate. Summary statistics were used to describe study characteristics and findings. Results A total of 2,078 studies were identified, 1,587 were unique, and 1,243 were excluded based on titles/abstracts. Among 344 full-text articles, 73 studies were eligible: 2 ductal carcinoma in situ (DCIS), 4 chronic lymphocytic leukemia (CLL), 6 renal cell carcinoma (RCC) and 61 prostate cancer. The most influential determinant of initiating AS was physician recommendation. Others included higher socioeconomic status, smaller tumor size, comorbid disease, older age, and preference to avoid adverse treatment effects. AS patients desired more information about AS and reassurance about future treatment options, involvement in decision-making and assessment of illness uncertainty and supportive care needs during follow-up. Only three studies of prostate cancer evaluated interventions to improve AS communication or experience. Conclusions This study revealed a paucity of research on AS communication for DCIS, RCC and CLL, but generated insight on how to optimize AS discussions in the context of routine care or clinical trials from research on AS for prostate cancer. Further research is needed on AS for patients with DCIS, RCC and CLL, and to evaluate interventions aimed at patients and/or providers to improve AS communication, experience and associated outcomes.
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Hinchcliff E, Melamed A, Bregar A, Diver E, Clemmer J, Del Carmen M, Schorge JO, Alejandro Rauh-Hain J. Factors associated with delivery of neoadjuvant chemotherapy in women with advanced stage ovarian cancer. Gynecol Oncol 2017; 148:168-173. [PMID: 29128105 DOI: 10.1016/j.ygyno.2017.10.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/30/2017] [Accepted: 10/31/2017] [Indexed: 02/01/2023]
Abstract
PURPOSE To identify clinical and non-clinical factors associated with utilization of primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy (NACT) in women with advanced stage epithelial ovarian cancer (EOC). METHODS Using the National Cancer Database, we identified women with stage IIIC and IV EOC diagnosed from 2012 to 2014. The primary outcome was receipt of NACT, defined in the primary analysis as utilization of chemotherapy as the first cancer-directed therapy, irrespective of whether interval surgery was performed. Univariable and multivariable associations between clinical and non-clinical factors and receipt of NACT were investigated using mixed-effect logistic regression models. A secondary analysis excluded women who received primary chemotherapy but did not receive interval cytoreductive surgery. RESULTS Among 17,302 eligible women, 10,948 (63.3%) underwent PCS and 6354 (36.7%) received NACT. Older age, stage IV disease, high-grade, and serous histology were associated with receipt of NACT in univariate (p<0.001) and multivariable analyses (p<0.001). Analysis of non-clinical factors revealed that residency in the Northeast region and receipt of treatment closer to home were associated with NACT in univariate (p<0.05) but not multivariable analysis (p>0.05). In multivariable analysis, African-American race/ethnicity (p=0.04), low-income level (p=0.02), treatment in high-volume centers (p<0.01), and insurance by Medicare or other government insurance (p<0.001) were associated with receipt of NACT. When women who received no surgery were excluded, all factors that were independent predictors of NACT in the main analysis remained significant, except for race/ethnicity. CONCLUSIONS Non-clinical factors were associated with the use of NACT at a magnitude similar to that of clinically relevant factors.
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Affiliation(s)
- Emily Hinchcliff
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA, United States.
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Amy Bregar
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Elisabeth Diver
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - Joel Clemmer
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States
| | - Marcela Del Carmen
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - John O Schorge
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
| | - J Alejandro Rauh-Hain
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States
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Katsnelson J, Barnes RJ, Patel HA, Monie D, Kaufman T, Hellenthal NJ. Effect of median household income on surgical approach and survival in renal cell carcinoma. Urol Oncol 2017; 35:541.e1-541.e6. [PMID: 28549821 DOI: 10.1016/j.urolonc.2017.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/28/2017] [Accepted: 05/05/2017] [Indexed: 01/20/2023]
Abstract
PURPOSE We sought to determine whether median household income (MHI) independently predicts surgical approach (partial vs. radical nephrectomy) and survival in patients with renal cell carcinoma. METHODS The U.S. Surveillance Epidemiology and End Results Database (1988-2011) was queried to examine kidney cancer cases and linked to the Area Health Resources File. We correlated surgical approach and survival, both overall and cancer-specific, with tumor stage, age, race, sex, and income data. RESULTS Of 152,589 patients diagnosed with renal cell carcinoma, 24,221 (16%) patients underwent partial nephrectomy, 102,771 (67%) patients underwent radical nephrectomy, and 25,597 (17%) patients had no surgery. There was no significant difference in stage of presentation between the wealthiest and poorest MHI quartiles, with approximately 35% of patients in each quartile presenting with T1aN0M0 disease and 17% of patients presenting with metastatic disease. Despite this, 18% of patients in the wealthiest quartile underwent partial nephrectomy compared to 14% of patients in the poorest quartile. Although the percentage of patients undergoing partial nephrectomy rose over the timeframe studied in both the wealthiest and poorest quartiles, the rate of rise was highest in the wealthier group. Those in the poorest quartile were 0.10 times more likely to die of all causes (95% CI: 1.09-1.11, P<0.001) and 0.09 times more likely to die of kidney cancer (95% CI: 1.05-1.10, P<0.001) than those in the wealthiest quartile over the timeframe studied. CONCLUSIONS Despite presenting with similar stage, patients with lower MHI less commonly undergo partial nephrectomy and are more likely to die of kidney cancer than those in the highest MHIs.
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Affiliation(s)
| | | | - Hunaiz A Patel
- Department of Surgery, Bassett Healthcare, Cooperstown, NY
| | - Daphne Monie
- Department of Surgery, Bassett Healthcare, Cooperstown, NY
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Colicchia M, Karnes RJ. Re: Treatment for T1a Renal Cancer Substratified by Size: “Less is More”. J Urol 2017; 197:1171-1172. [DOI: 10.1016/j.juro.2016.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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National Utilization of Partial Nephrectomy Pre- and Post- AUA Guidelines: Is This as Good as It Gets? Clin Genitourin Cancer 2017; 15:591-597.e1. [PMID: 28410908 DOI: 10.1016/j.clgc.2017.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 03/10/2017] [Accepted: 03/12/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND The purpose of the study was to compare utilization and predictors of partial nephrectomy (PN) in the pre- and post-guideline eras. MATERIALS AND METHODS American Board of Urology certification/recertification operative logs were reviewed from 2003 to 2014. Nephrectomy cases were extracted using Current Procedural Terminology codes. The cases were then stratified according to pre-guidelines (2003-October 2009) and post-guidelines (November 2009-2014). Multivariable logistic regression was used to evaluate patient, surgeon, and practice characteristics as predictors of PN. A general linear model with regression analysis was used to evaluate the change in PN over time relative to the incidence of renal cell carcinoma (RCC). RESULTS We identified 20,402 and 20,729 nephrectomies in the pre- and post-guidelines eras, respectively. In multivariable analysis, the post-guidelines group was more likely to undergo PN (odds ratio, 1.87; P < .001). The pre- as well as post-guidelines groups had a higher likelihood of undergoing PN with an open approach, higher-volume surgeons, and younger patient age (P < .05). Surgeon subspecialty and US region were no longer significant factors after guidelines publication. Number of PN normalized to the incidence of RCC continued to increase over time (0.14%/y; R2 = 0.77; P < .001). CONCLUSION Partial nephrectomy in the post-guidelines era is no longer confined to urological subspecialists or certain densely populated US regions. Although rates of PN continue to increase relative to the recently decreasing overall incidence of RCC, the slope has leveled off somewhat. This is likely related to clinical intricacies of the best treatment modality and technologic advances rather than changes related to guidelines publication.
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Abstract
Renal cell carcinoma is a common malignancy with increasing incidence due to the incidental detection of non-symptomatic small renal masses on imaging. Management of these small tumors has evolved toward minimally invasive nephron-sparing techniques which include partial nephrectomy and image-guided ablation. Cryoablation and radiofrequency ablation are the most utilized ablation modalities with the former more suited for larger and central renal masses due to intra-procedural visualization of the ablation zone and reduced pelvicalyceal injury. In this article, we review the epidemiology and natural history of renal cell carcinoma, the role of biopsy, and the management options available-surgery, image-guided ablation, and active surveillance-with a focus on cryoablation. The clinical outcomes of the longer term maturing cryoablation data are discussed with reference to partial nephrectomy and radiofrequency ablation. Image-guided ablation has often been the management choice in patients deemed unfit for surgery; however, growing evidence from published series demonstrates image-guided ablation as a sound alternative treatment with equivalent oncological outcomes and minimal patient impact.
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Affiliation(s)
- Nirav Patel
- Department of Radiology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, United Kingdom.
| | - Alexander J King
- Department of Radiology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, United Kingdom
| | - David J Breen
- Department of Radiology, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, United Kingdom
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Reply by the Authors. Urology 2015; 88:230. [PMID: 26683749 DOI: 10.1016/j.urology.2015.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 12/01/2015] [Accepted: 12/01/2015] [Indexed: 11/23/2022]
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Morlacco A, Karnes RJ. Re: Maurice et al: Nonclinical Factors Predict Selection of Initial Observation for Renal Cell Carcinoma (Urology 2015;86:892-900). Urology 2015; 88:229. [PMID: 26680243 DOI: 10.1016/j.urology.2015.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Alessandro Morlacco
- Department of Urology, Mayo Clinic, Rochester, MN; Department of Surgical, Oncological and Gastroenterological Sciences, Urology Clinic, University of Padova, Padova, Italy
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Mittakanti HR, Leppert JT. Editorial Comment. Urology 2015; 86:899. [PMID: 26590035 DOI: 10.1016/j.urology.2015.06.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - John T Leppert
- Department of Urology, Stanford University School of Medicine, Stanford, CA; Veterans Affairs Palo Alto Healthcare System, Palo Alto, CA
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Maurice MJ, Abouassaly R. Reply. Urology 2015; 86:899-900. [PMID: 26590036 DOI: 10.1016/j.urology.2015.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Matthew J Maurice
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH
| | - Robert Abouassaly
- Urology Institute, University Hospitals Case Medical Center, Cleveland, OH
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Maurice MJ, Zhu H, Kiechle JE, Kim SP, Abouassaly R. Increasing Biopsy Utilization for Renal Cell Carcinoma Is Closely Associated With Treatment. Urology 2015; 86:906-13. [PMID: 26342316 DOI: 10.1016/j.urology.2015.08.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/13/2015] [Accepted: 08/24/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe recent temporal trends in biopsy use for renal cell carcinoma and to identify factors associated with biopsy. MATERIALS AND METHODS Renal cell carcinoma diagnoses from 2003 to 2011 were identified using the National Cancer Data Base. Cases were classified by traditional (clinical stage T4, N1, or M1, or history of other malignancies) or expanded biopsy indications. Time trends were plotted, and multivariate analysis was performed to identify factors associated with biopsy. RESULTS Of 171,406 eligible patients, we identified 21,019 patients (12.3%) who were biopsied. We observed a significant increase in biopsy usage with time for both the traditional (range, 16.7%-20.6%) and expanded (range, 6.9%-10.9%) subgroups (P < .01 for the trends). By the end of the study period, expanded indications accounted for most biopsies. By far, eventual treatment was the strongest factor associated with biopsy utilization for either subgroup. Compared with patients treated with partial nephrectomy, the odds of being biopsied were 2.7-4.3, 6.0-9.8, 14.6-23.0, and 3.0-4.4 times higher for patients managed with observation, cryoablation, radiofrequency ablation, or chemotherapy (including targeted therapy), respectively (P < .01). In the expanded-indications subgroup, other factors significantly associated with biopsy included sex, race, income, insurance, travel distance, case volume, region, and tumor size (P < .01 for all). Other significant factors in the traditional-indications subgroup were income, region, and Charlson score (P < .01 for all). CONCLUSION In recent years, renal cell carcinoma biopsy has been increasingly used in patients with traditional and expanded indications. Its use is strongly associated with treatment and treatment-related factors.
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Affiliation(s)
- Matthew J Maurice
- Urology Institute, University Hospitals Case Medical Center, Cleveland, OH; Division of Urology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Hui Zhu
- Division of Urology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH; Cleveland Clinic, Glickman Urologic and Kidney Institute, Cleveland, OH
| | - Jonathan E Kiechle
- Urology Institute, University Hospitals Case Medical Center, Cleveland, OH; Division of Urology, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Simon P Kim
- Urology Institute, University Hospitals Case Medical Center, Cleveland, OH
| | - Robert Abouassaly
- Urology Institute, University Hospitals Case Medical Center, Cleveland, OH.
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