Patient preferences for cancer screening in chronic kidney disease: a best-worst scaling survey

BACKGROUND

Despite an increased cancer risk for patients with chronic kidney disease (CKD), uptake of cancer screening varies due to competing priorities and complex health-related issues. This study aimed to elicit the preferences and important attributes of cancer screening in patients with CKD.

METHODS

An on-line best-worst scaling survey was used to ascertain the relative importance of 22 screening attributes among CKD patients using an incomplete block design. Preference scores (0-1) were calculated by multinomial logistic regression. Preference heterogeneity was evaluated.

RESULTS

The survey was completed by 83 patients: 26 not requiring kidney replacement therapy, 20 receiving dialysis and 37 transplant recipients (mean age 59 years, 53% men, 75% prior to cancer screening). The five most important attributes were early detection {preference score 1.0 [95% confidence interval (CI) 0.90-1.10]}, decreased risk of cancer death [0.85 (0.75-0.94)], false negatives [0.71 (0.61-0.80)], reduction in immunosuppression if detected [0.68 (0.59-0.78)] and non-invasive interventions after positive results [0.68 (0.59-0.78)]. Preference heterogeneity reflected the stage of CKD. Immunosuppression reduction [mean difference 0.11 (95% CI 0.02-0.19)] and views of family/friends [0.10 (reference attribute)] were important for transplant recipients. Screening frequency [-0.18 (95% CI -0.26 to -0.10)] and overdiagnosis of harmless cancers [-0.14 (95% CI -0.22 to -0.10)] were important for dialysis patients.

CONCLUSION

Early detection, risk of cancer-related death, false negatives, immunosuppression reduction and non-invasive interventions following detection are important cancer screening considerations among CKD patients. Patient preferences are key to shared decision-making and individualized cancer screening.

Nephrologists' perspectives on cancer screening in patients with chronic kidney disease: An interview study

AIM

Patients with chronic kidney disease (CKD) have an increased risk of cancer compared with the general population. Despite this, there is considerable variability in cancer screening practices among nephrologists that may reflect uncertainties about the benefits and harms of screening, the additional costs, and competing priorities among the complex issues that patients are confronted with. We aimed to describe nephrologists' perspectives and approaches to cancer screening in CKD.

METHODS

Semi-structured interviews were conducted with 29 nephrologists from 15 units across Australia and New Zealand. Interviews were transcribed and thematically analyzed.

RESULTS

Five themes were identified: empowering patients to make informed decisions (respecting patient preferences, communicating evidence-based recommendations, creating awareness of consequences, preparing for transplantation); justifiable risk taking (avoiding undue consequences in vulnerable populations, balancing the costs and benefits, warranted by long term immunosuppression, assurance of reasonable survival gains); ambiguity of evidence in supporting decisions (absence of standardized recommendations, limited transferability of population-based data); depending on a shared multidisciplinary approach (collaboration with primary health care, access to coordinated skin cancer clinics); and prioritizing current or imminent complications.

CONCLUSION

Nephrologists approach decisions about cancer screening in patients with CKD based on patient preferences, assessment of risk, justifiable survival gains, and current health priorities. Evidence-based guidelines, communication frameworks and specialist clinics may support informed and shared decision making about cancer screening in CKD.

Risk of cancer in pre-dialysis chronic kidney disease: A nationwide population-based study with a matched control group

Background

Cancer risk and epidemiology in pre-dialysis chronic kidney disease (CKD) warrant further investigation in a large-scale cohort.

Methods

We performed a nationwide population-based study using the national health insurance database of Korea. We screened records from 18,936,885 individuals who received a national health examination ≥ 2 times from 2009 to 2016. Pre-dialysis CKD was identified based on serum creatinine and dipstick albuminuria results. Individuals with preexisting cancer history, renal replacement therapy, or transient CKD were excluded. A control group without evidence of kidney function impairment and matched for age, sex, low-income status, and smoking history was included. Risk of cancers, as identified in the claims database, was investigated using a multivariable Cox regression model including matched variables and other unmatched clinical characteristics as covariates.

Results

A total of 471,758 people with pre-dialysis CKD and the same number of matched controls were included. Urinary (adjusted hazard ratio [HR], 1.97; 95% confidence interval [95% CI], 1.82–2.13) and hematopoietic (adjusted HR, 1.53; 95% CI, 1.38–1.68) malignancy risk was increased in pre-dialysis CKD and all CKD stages. However, the risk of digestive cancer was lower in the pre-dialysis CKD group (adjusted HR, 0.89; 95% CI, 0.87–0.92). The risk of digestive, respiratory, thyroid, and prostate malignancy demonstrated a non-linear association with CKD stage, with stage 1 or stage 4/5 CKD without dialysis demonstrating relatively lower risk.

Conclusion

Cancer risk varied in pre-dialysis CKD compared to controls, and the association between cancer risk and CKD stage varied depending on the cancer type.

Dialysis physicians' referral behaviors for hemodialysis patients suspected of having cancer: A vignette-based questionnaire study

BACKGROUND

Although cancer management in dialysis patients has become a commonly encountered issue, known as "onco-nephrology", few evidence-based clinical recommendations have been proposed. Here, we examined the variation in referral behaviors adopted by dialysis physicians on encountering dialysis patients with signs/symptoms suggestive of cancer.

METHODS

We conducted a vignette-based study in August 2015. We sent a 14-page questionnaire to 191 dialysis physicians, including the representative dialysis facilities participating in a Japanese dialysis cohort (the Japan Dialysis Outcomes and Practice Patterns Study). Using vignette scenarios for respiratory, digestive, and urological areas, we assessed the referral behaviors (expert referral or not) adopted by dialysis physicians on encountering dialysis patients with symptoms suggestive of cancer. Each scenario contained three patient functional factors: age (60 or 75 years), performance status (PS 0 or 1), and cognitive dysfunction (absence or presence). We examined the association between physician factors, patient factors, and referral behaviors.

RESULTS

We obtained 94 replies (response rate: 49.2%). For the respiratory scenarios, 38.3% and 51.9% of physicians reported watchful waiting when encountering bilateral and unilateral pleural effusion, respectively. In digestive and urologic scenarios, most physicians (>85%) selected expert referral. We detected differences in referral behaviors between scenarios with different cancer biological factors. However, we found consistency in referral behaviors within the same scenario, even with different patient functional factors (intra-class correlation coefficients within each scenario all >0.7).

CONCLUSIONS

Physicians' referral behaviors for dialysis patients suspected of having cancer vary for different cancer biological factors (probability of having cancer). However, the referral behaviors are similar for different patient functional factors (age, PS, and cognitive dysfunction).

Solid Organ Cancer and Melanoma in Kidney Transplant Recipients: TumorTx Base Preliminary Results

BACKGROUND

Incidence of malignancy in transplant recipients is higher than in the general population. Malignancy is a major cause of mortality following solid organ transplantation and a major barrier to long-term survival for the kidney. The aim of this study was to estimate the incidence of solid organ malignancy (SOM) and melanoma in renal transplant recipients (RTR) transplanted at 2 representative transplant centers in Poland based on data from the Polish Tumor Registry.

MATERIAL AND METHODS

We analyzed the medical data of 3069 patients who underwent kidney transplantation (KTx) between 1995 and 2015.

RESULTS

In our study 112 SOM (3.6%) were diagnosed. The majority of patients were male (n = 71; 63.4%; P < .01). The mean age at KTx was 48.0 ± 13.1 years and the mean age at the time of cancer diagnosis was 55.9 ± 12.7 years. The average time of malignancy occurrence was 5.9 ± 5.0 years after KTx. SOM was the cause of death in 60 patients (53%). The most common were malignancies of gastrointestinal tract (25%), urinary tract tumors (23.2%), lung cancer (n = 18; 16%), and lymphoma (13.4%). We found an increase in the percentage of chronic glomerular nephropathy in the group of SOM (n = 56; 50%) compared with renal insufficiency of other etiologies.

CONCLUSIONS

RTR in Poland are at a significant risk of malignancy development in a variety of organs, primarily urinary tract tumors and lymphoma. Cancers most frequently occurring in the general population such as lung and colorectal cancer are common in our RTR. On this basis an appropriate tumor screening schedule can be developed in individual countries.

The Novel Application of Genomic Profiling Assays to Shorten Inactive Status for Potential Kidney Transplant Recipients With Breast Cancer

The concern about cancer recurrence has traditionally resulted in delaying kidney transplantation for 2-5 years after a cancer diagnosis in patients who are otherwise eligible for transplant. This period of inactive status to observe the tumor biology can result in significant morbidity and decreased quality of life for patients with end-stage renal disease (ESRD). We reported the novel application of genomic profiling assays in breast cancer to identify low-risk cancers in two patients with ESRD who were able to have the mandatory inactive status eliminated prior to kidney transplantation.

Comparison of trends in colorectal cancer screening in the US end-stage renal disease population and the US Medicare population

Background

Methods

Results

Conclusions

Onco-nephrology: an appraisal of the cancer and chronic kidney disease links

A bidirectional relationship has been observed for kidney disease and cancer. On the one hand, cancer is an important complication noted in kidney disease as well as a major cause of morbidity and mortality in this group. On the other hand, improved cancer treatment has prolonged survival, but also increased the development of acute and chronic kidney disease. The combination of cancer and kidney disease makes it challenging for clinicians to provide comprehensive and safe therapies for this group of patients. As such, clinicians caring for this group must develop expertise and become competent in the practice of a newly evolving subspecialty of nephrology known as 'onco-nephrology'. This brief narrative review will focus on the cancer risk in patients with underlying kidney disease, the therapies such as erythropoiesis-stimulating agents on cancer progression and other outcomes, and the appropriate dosing of anti-cancer agents in patients with underlying kidney disease.

Awareness of cancer screening during treatment of patients with renal failure: a physician survey in Turkey

BACKGROUND

Today, survival rate of patients with chronic renal failure/hemodialysis has increased so that chronic illnesses are more likely to occur. Cancer is the main cause of morbidity and mortality in such patients.

AIM

In this study, physician attitudes were examined about cancer screening in patients with renal failure.

MATERIALS AND METHODS

This study was done by face to face questionnaire in the 27th National Nephrology Congress to determine if the physicians dealing with chronic renal failure, hemodialysis or renal transplanted patients, recommend cancer screening or not and the methods of screening for cervix, prostate, breast and colon cancer.

RESULTS

One hundred and fifty six physicians were included in the survey. A total of 105 (67%) participants were male and the age of responders was 48 ± 9 years. About 29% were specialists in nephrology, 28% internal medicine, and 5% were other areas of expertise. Some 48% of participants were hemodialysis certified general practitioners. Patients were grouped as compensated chronic renal failure, hemodialysis or renal transplanted. Of the 156 responders, 128 (82%) physicians recommended breast cancer screening and the most recommended subgroup was hemodialysis patients (15%). The most preferred methods of screening were combinations of mammography, self breast examination and physician breast examination. 112 (72%) physicians recommended cervix cancer screening, and the most preferred method of screening was pap-smear. Colon cancer screening was recommended by 102 (65%) physicians and prostate screening by 109 (70%) physicians. The most preferred methods of screening were fecal occult blood test and PSA plus rectal digital test, respectively.

CONCLUSIONS

It is not obvious whether cancer screening in renal failure patients is different from the rest of society. There is a variety of screening methods. An answer can be found to these questions as a result of studies by a common follow-up protocol and cooperation of nephrologists and oncologists.

Incidental renal cell carcinoma originating from a native kidney after en-bloc resection for adrenal carcinoma in a kidney transplant recipient

BACKGROUND

Renal transplantation is the best treatment for patients with end-stage renal disease. Although there is significantly increased risk of malignancy after renal transplantation, carcinoma of the native kidney is very rare, and moreover, the risk of endocrinologic malignancy after renal transplantation is lower than in the general population and adrenal cortical carcinoma extremely rare. We report a case of incidental renal cell carcinoma originating from a native kidney after en-bloc resection for adrenal carcinoma in a kidney transplant recipient.

CASE REPORT

A 57 year-old male patient had undergone living-donor kidney transplantation for chronic renal failure from hypertension 15 years earlier and had a right adrenal tumor diagnosed on surveillance abdomen-pelvis computerized tomography. Based on 24-hour catecholamine laboratory findings, nonfunctioning tumor was suspected. The planned en-bloc resection of right adrenal gland and right native kidney combining the perirenal tissue and Gerota fascia was performed, because the tumor was suspicious for malignancy and could possibly invade the perirenal tissue or right kidney. On the final pathology, combined adrenal cortical carcinoma and incidental renal cell carcinoma was confirmed. Renal cell carcinoma was papillary, type I, and stage T1N0M0. Adrenal cortical carcinoma was 7.6 × 6.5 cm in size, had marked nuclear atypia, and was grade IV/IV. Mitotic counts were >10 per high-power field, but it had no capsular invasion or vascular invasion, and free resection margin was confirmed. In the preoperative period, he had taken immunosuppressants FK506 and mycophenolate sodium, but after combined carcinomas were confirmed, the regimen of combination of immunosuppressants was changed to sirolimus with low-dose FK506 and half-dose mycophenolate sodium.

Immunosuppression and risk of cervical cancer

A markedly increased risk of cervical cancer is known in women immunosuppressed due to AIDS or therapy following organ transplantation. The aim of this review is to determine the association between other conditions affecting the immune system and the risk of cervical cancer. Patients with end-stage renal disease seem to be at an increased risk of cervical cancer. A higher risk of cervical precancerous lesions was found in patients with some autoimmune diseases; particularly if treated with immunosuppressants. Among behavioral factors weakening the immune system, smoking appeared to strongly increase the risk of cervical cancer, while poor diet only moderately increased the risk. It is difficult to determine whether sexually transmitted infections other than human papillomavirus infection are independent risk factors. Identifying those groups of women likely to fail in clearing persistent human papillomavirus infections would help individualize screening guidelines and target immune-associated factors in the cervical cancer etiology.

Comparison of de novo cancer incidence in Australian liver, heart and lung transplant recipients

Population-based evidence on the relative risk of de novo cancer in liver and cardiothoracic transplant recipients is limited. A cohort study was conducted in Australia using population-based liver (n = 1926) and cardiothoracic (n = 2718) registries (1984-2006). Standardized incidence ratios (SIRs) were computed by cancer type, transplanted organ and recipient age. Cox regression models were used to compare cancer incidence by transplanted organ. During a median 5-year follow-up, the risk of any cancer in liver and cardiothoracic recipients was significantly elevated compared to the general population (n = 499; SIR = 2.62, 95%CI 2.40-2.86). An excess risk was observed for 16 cancer types, predominantly cancers with a viral etiology. The pattern of risk by cancer type was broadly similar for heart, lung and liver recipients, except for Merkel cell carcinoma (cardiothoracic only). Seventeen cancers (10 non-Hodgkin lymphomas), were observed in 415 pediatric recipients (SIR = 23.8, 95%CI 13.8-38.0). The adjusted hazard ratio for any cancer in all recipients was higher in heart compared to liver (1.29, 95%CI 1.03-1.63) and lung compared to liver (1.65, 95%CI 1.26-2.16). Understanding the factors responsible for the higher cancer incidence in cardiothoracic compared to liver recipients has the potential to lead to targeted cancer prevention strategies in this high-risk population.

Cancer screening in people who have chronic disease: the example of kidney disease

Cancer screening in people with chronic illness has been the subject of considerable debate recently. Despite the increased incidence of cancer and higher risk of cancer deaths in selected populations, such as those with kidney disease, the benefits-to-harms ratio of cancer screening is uncertain and is likely to be different to people without chronic illnesses because of the expected higher competing risk of death from disease other than cancer, and a higher risk of complications associated with the screening, the diagnostic, and the treatment processes. Using kidney disease as an example, the authors reviewed the current evidence for early cancer detection through screening in people with two or more coexistent chronic diseases, discussed the accepted principles underpinning cancer screening, and the applicability of these concepts to individuals with chronic disease. This review suggests that future research that evaluates the screening test accuracy, quality of life of having cancer, and cancer treatment effectiveness, targeting those with chronic illnesses are necessary for the development of an effective, safe, and acceptable cancer screening program among people with two or more chronic diseases.

Test performance of faecal occult blood testing for the detection of bowel cancer in people with chronic kidney disease (DETECT) protocol

Background

Cancer is a major cause of mortality and morbidity in patients with chronic kidney disease (CKD). In patients without kidney disease, screening is a major strategy for reducing the risk of cancer and improving the health outcomes for those who developed cancers by detecting treatable cancers at an early stage. Among those with CKD, the effectiveness, the efficacy and patients' preferences for cancer screening are unknown.

Methods/Design

This work describes the protocol for the DETECT study examining the effectiveness, efficiency and patient's perspectives of colorectal cancer screening using immunochemical faecal occult blood testing (iFOBT) for people with CKD. The aims of the DETECT study are 1) to determine the test performance characteristics of iFOBT screening in individuals with CKD, 2) to estimate the incremental costs and health benefits of iFOBT screening in CKD compared to no screening and 3) to elicit patients' perspective for colorectal cancer screening in the CKD population. Three different study designs will be used to explore the uncertainties surrounding colorectal cancer screening in CKD. A diagnostic test accuracy study of iFOBT screening will be conducted across all stages of CKD in patients ages 35-70. Using individually collected direct healthcare costs and outcomes from the diagnostic test accuracy study, cost-utility and cost-effective analyses will be performed to estimate the costs and health benefits of iFOBT screening in CKD. Qualitative in-depth interviews will be undertaken in a subset of participants from the diagnostic test accuracy study to investigate the perspectives, experiences, attitudes and beliefs about colorectal cancer screening among individuals with CKD.

Discussion

The DETECT study will target the three major unknowns about early cancer detection in CKD. Findings from our study will provide accurate and definitive estimates of screening efficacy and efficiency for colorectal cancer, and will allow better service planning and budgeting for early cancer detection in this at-risk population.

The DETECT study is also registered with the Australia New Zealand Clinical Trials Registry ACTRN12611000538943

Chronic kidney disease and cancer: a troubling connection

Chronic kidney disease (CKD) and cancer are connected in a number of ways in both directions: cancer can cause CKD either directly or indirectly through the adverse effects of therapies; CKD may, conversely, be a risk factor for cancer; and both may be associated because they share common risk factors, often toxins. In this review, we briefly address the issue of paraneoplastic nephropathies as well as that of toxin-related cancers and CKD, including analgesic and aristolochic acid nephropathies. We then focus on the links between the various stages of CKD and cancer incidence, and critically examine major epidemiologic surveys in the field. Compared with the general population, kidney transplant recipients have a threefold to fourfold increase in overall cancer risk, and relative risks higher than 3 for about 20 specific tumors, most, but not all, of which are known or suspected to be caused by viral agents. After dialysis, cancer risk increases 10% to 80% according to studies, with relative risks significantly higher than in the general population, for about 10 cancer sites. There is emerging evidence for an excess risk of cancer in patients in early CKD stages.

Survey on human papillomavirus/p16 screening use in oropharyngeal carcinoma patients in the United States

BACKGROUND

Patients with human papillomavirus (HPV)-positive oropharyngeal carcinoma (OC) have better prognosis than patients with HPV-negative OC. The objective of the current study was to assess how different practices across the United States treat patients with OC with respect to screening for HPV DNA or p16.

METHODS

Five hundred forty-two randomly selected radiation oncologists were sent an 11-question survey by email regarding the use of HPV/p16 screening in OC. The questionnaire addressed demographics of the practice, intensity-modulated radiotherapy (IMRT) use, screening practices for HPV DNA or p16, which year this began, the use of HPV or p16 data to direct patient care, and future plans for its use if it had not already been instituted.

RESULTS

One hundred ninety-two responses (39.6%) were received. Thirty-five percent of respondents (67 of 188) reported screening for HPV DNA routinely, whereas 4.8% of respondents (9 of 188) reported screening for p16. Of the physicians who did not use screening techniques, 37.2% (44 of 118 respondents) reported future plans to institute these screening techniques, 20% (9 of 45 respondents) stated plans to institute these techniques in the next 6 months, 55.5% (25 of 45 respondents) stated plans to institute these techniques within 6 months to 1 year, and 22.2% (10 of 45 respondents) stated plans to institute these techniques within 1 to 2 years. Academic physicians were more likely to use screening techniques (62.7%; P < .001) compared with private practitioners (31.4%). Only 12.4% of respondents reported using HPV or p16 data to direct care.

CONCLUSIONS

Approximately 40.4% of radiation oncology practices that responded to a survey in the United States screened for HPV DNA or p16 in OC, whereas only 12.4% used it to further direct care. This number appears to be growing rapidly. Clinical trials to further elucidate how HPV or p16 status should direct care in OC are warranted.