Conditional survival after nephrectomy for renal cell carcinoma (RCC): changes in future survival probability over time

Contemporary conditional cancer-specific survival rates in surgically treated nonmetastatic primary urethral carcinoma

BACKGROUND

We examined the effect of disease-free interval (DFI) duration on cancer-specific mortality (CSM)-free survival, otherwise known as the effect of conditional survival, in radical urethrectomy nonmetastatic primary urethral carcinoma (PUC) patients.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) database 2000-2020, patient (age, sex, race/ethnicity, and marital status) and tumor (stage and histology) characteristics, as well as systemic therapy exposure status of nonmetastatic PUC patients were tabulated. Conditional survival estimates at 5-year were assessed based on DFI duration and according to stage at presentation (T1 -2N0 vs. T3-4N0-2).

RESULTS

Of all 512 radical urethrectomy PUC patients, 278 (54%) harbored T1-2N0 stage versus 234 (46%) harbored T3-4N0-2 stage. In 512 PUC patients, 5-year CSM-free survival at initial diagnosis was 61.8%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 85.6%. In 278 T1-2N0 PUC patients, 5-year CSM-free survival at initial diagnosis was 68.4%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 86.9%. In 234 T3-4N0-2 PUC patients, 5-year CSM-free survival at initial diagnosis was 53.8%. Provided a DFI duration of 36 months, 5-year CSM-free survival was 83.6%.

CONCLUSIONS

Although intuitively, clinicians and patients are well aware of the concept that increasing DFI duration improves survival probability, only a few clinicians can accurately estimate the magnitude of survival improvement, as was done within the current study. Such information is crucial to survivors, especially in those diagnosed with rare malignancies, where the survival estimation according to DFI duration is even more challenging.

Conditional survival of stage III non-seminoma testis cancer patients

PURPOSE

In many primaries other than non-seminoma testis cancer, the risk of death due to cancer decreases with increasing disease-free interval duration after initial diagnosis and treatment. This effect is known as conditional survival and is relatively unexplored in stage III non-seminoma patients, where it may matter most in clinical decision-making. We examined the effect of disease-free interval duration on overall survival in stage III non-seminoma patients.

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results Database (2004-2018), stage III non-seminoma patients were identified. Multivariable Cox regression analyses and conditional survival models were applied.

RESULTS

Of 2,092 surgically treated stage III non-seminoma patients, 385 (18%) exhibited good vs. 558 (27%) intermediate vs. 1,149 (55%) poor prognosis. In multivariable Cox regression models, poor prognosis group independently predicted overall mortality (HR 3.3, P < 0.001). In conditional survival analyses based on 36 months' disease-free interval duration, 5-year overall survival estimates were as follows: good prognosis patients 96 vs. 89% at initial diagnosis without accounting for disease-free interval duration (Δ=+7); intermediate prognosis patients 94 vs. 85% at initial diagnosis without accounting for disease-free interval duration (Δ=+9); poor prognosis patients 94 vs. 65% at initial diagnosis without accounting for disease-free interval duration (Δ=+29).

CONCLUSIONS

Conditional survival estimates based on 36 months' disease-free interval duration provide a more accurate and more optimistic outlook for stage III non-seminoma patients than predictions defined at initial diagnosis, without accounting for disease-free interval duration.

Conditional survival of patients with low-risk prostate cancer: Temporal changes in active surveillance permanence over time

PURPOSE

To determine risk categories for patients with prostate cancer (PCa) in active surveillance (AS) and to test the conditional survival (CS) that examined the effect of event-free survival since AS-entrance.

MATERIALS AND METHODS

From January 2012 to December 2020 we analyzed 606 patients with PCa enrolled in our AS program. Kaplan-Meier (KM) plots depicted AS-exit rate. Multivariable Cox regression models (MCRMs) tested for AS-exit rate independent predictors to determine risk categories. CS estimates were used to calculate overall AS-exit rate after event-free survival intervals of 1, 2, 3, and 5 years, and after stratification according to risk categories.

RESULTS

At MCRMs PSAd ≥ 0.15 (HR: 1.43; P-value 0.04), PI-RADS 4-5 (HR: 2.56; P-value <0.001) and number of biopsy positive cores ≥ 2 (HR: 1.75; P-value <0.001) were independent predictors of AS-exit. These variables were used to determine risk categories: low-, intermediate- and high-risk. Overall, according to CS-analyses, 5-year AS-exit free rate increased from 59.7% at baseline, to 67.3%, 74.7%, and 89.4% in patients who remained in AS respectively ≥1, ≥2, ≥3 and ≥5 years. After stratification according to risk categories, in those patients who remained in AS ≥ 5 years, 5-year AS-exit free rates increased from 76.3% to 100% in patients with a low-risk, from 62.7% to 83.7% in patients with an intermediate-risk and from 42.3% to 87.5% in patients with a high-risk.

CONCLUSIONS

CS models showed a direct relationship between event-free survival duration and subsequent AS permanence in overall PCa patients and after stratification according to risk categories.

Conditional survival for non-metastatic muscle-invasive adenocarcinoma of the urinary bladder after radical cystectomy

PURPOSE

To test the effect of conditional survival on 36-months' cancer-specific mortality (CSM)-free survival in non-metastatic muscle-invasive adenocarcinoma of the bladder (ACB).

MATERIALS AND METHODS

Within the Surveillance, Epidemiology, and End Results database (2000-2018), ACB patients treated with radical cystectomy (RC) were identified. Multivariable competing risks regression (CRR) analyses assessed the independent predictor status of organ-confined (OC, T₂N₀M₀) vs non-organ-confined stage (NOC, T_3-4N₀M₀ or T_anyN_1-3M₀) on CSM. Conditional 36-months' CSM-free survival estimates were computed based on event-free intervals of 12, 24, 36, 48 and 60 months after RC, according to stage.

RESULTS

Of 475 ACB patients, 132 (28%) harbored OC vs 343 (72%) harbored NOC stage. In multivariable CRR models, NOC vs OC stage independently predicted lower CSM (hazard ratio 3.55; 95% CI 2.66, 5.83; p < 0.001). Conversely, neither chemotherapy nor radiotherapy were independently associated with CSM. In OC stage, 36-months' CSM-free survival rate was 84% at baseline. Provided event-free intervals of 12, 24, 36, 48 and 60 months, conditional 36-months' CSM-free survival estimates were 84, 87, 87, 89 and 89%. In NOC stage, 36-months' CSM-free survival rate was 47% at baseline. Provided event-free intervals of 12, 24, 36, 48 and 60 months, conditional 36-months' CSM-free survival estimates were 51, 62, 69, 78 and 85%.

CONCLUSIONS

Conditional survival estimates provide better insight into survival of patients with longer event-free follow-up. In consequence, conditional survival estimates might be highly valuable for individual patient counselling.

Conditional survival after radical cystectomy for non-metastatic muscle-invasive squamous cell carcinoma of the urinary bladder: A population-based analysis

PURPOSE

To assess the effect of event-free survival duration on cancer-specific mortality (CSM) after radical cystectomy (RC) in nonmetastatic muscle-invasive squamous cell carcinoma of the urinary bladder.

METHODS

RC patients treated for non-metastatic muscle-invasive squamous cell carcinoma of the urinary bladder were identified within the Surveillance, Epidemiology, and End Results database (2000-2018). Independent predictor status for CSM of T and N stage groupings (i.e., T2N0, T3N0, T4N0, and TanyN1-3) was tested in multivariable Cox-regression models. Conditional 5-year CSM-free estimates were assessed at baseline and at 4 specific event-free survival times (i.e. 6, 12, 18 and 24 months), within each of the 4 examined stage groups.

RESULTS

Of 981 RC patients, 206 (21%), 416 (42%), 152 (16%), and 207 (21%) were T2N0, T3N0, T4N0, and TanyN1-3, respectively. In multivariable Cox-regression models T3N0 (HR 1.94), T4N0 (HR 5.22), and TanyN1-3 (HR 6.62) were independent predictors of CSM, relative to T2N0. In conditional survival analyses based on 24 months event-free status, survival estimates were: 89% for T2N0 vs. 76% at baseline (Δ = 13%), 84% for T3N0 vs. 58% at baseline (Δ = 26%), 69% for T4N0 vs. 25% at baseline (Δ = 44%), 69% for TanyN1-3 vs. 22% at baseline (Δ = 47%).

CONCLUSIONS

Event-free status at 24 months of follow-up is associated with substantially higher CSM-free survival than when CSM-free survival is predicted at baseline. The magnitude of this effect is most pronounced in TanyN1-3 and T4N0 patients, intermediate in T3N0 and more modest, nonetheless important, in T2N0.

Contemporary conditional cancer-specific survival rates in surgically treated adrenocortical carcinoma patients: A stage-specific analysis

BACKGROUND AND OBJECTIVES

We examined the effect of disease-free interval (DFI) duration on cancer-specific mortality (CSM)-free survival, otherwise known as the effect of conditional survival, in surgically treated adrenocortical carcinoma (ACC) patients.

METHODS

Within the Surveillance, Epidemiology, and End Results database (2004-2018), 867 ACC patients treated with adrenalectomy were identified. Conditional survival estimates at 5-years were assessed based on DFI duration and according to stage at presentation. Separate Cox regression models were fitted at baseline and according to DFI.

RESULTS

Overall, 406 (47%), 285 (33%), and 176 (20%) patients were stage I-II, III and IV, respectively. In conditional survival analysis, providing a DFI of 24 months, 5-year CSM-free survival at initial diagnosis increased from 66% to 80% in stage I-II, from 35% to 66% in stage III, and from 14% to 36% in stage IV. In multivariable Cox regression models, stage III (hazard ratio [HR]: 2.38; p < 0.001) and IV (HR: 4.67; p < 0.001) independently predicted higher CSM, relative to stage I-II. The magnitude of this effect decreased over time, providing increasing DFI duration.

CONCLUSIONS

In surgically treated ACC, survival probabilities increase with longer DFI duration. This improvement is more pronounced in stage III, followed by stages IV and I-II patients, in that order. Survival estimates accounting for DFI may prove valuable in patients counseling.

Collecting duct carcinoma: Epidemiology, clinical characteristics and survival

INTRODUCTION

Collecting duct carcinoma (CDC) is a rare renal malignancy. We relied on a large population-based cohort to address epidemiology, clinical characteristics, and treatment of CDC patients. We also tested survival in the overall cohort, as well as in stage-specific fashion.

MATERIALS AND METHODS

Within Surveillance, Epidemiology, and End Results (2004-2018) database, we identified 399 CDC patients. Based on Kaplan-Meier plots survival estimates, conditional survival rates were derived according to disease stage. Cox regression models tested for predictors of cancer specific mortality (CSM).

RESULTS

Overall, 273 (68.4%) patients were male, 236 (59.2%) had T3-4 stages, 148 (37.1%) had lymph node invasion, and 156 (39.1%) had distant metastases at initial diagnosis. Nephrectomy alone was commonest in stage I-II (n = 91/99, 92%) and III (n = 94/116, 81%). Combination of both nephrectomy and systemic therapy was commonest in stage IV (n = 62/172, 36%). In the overall cohort, median cancer specific survival was 18 months. Provided a disease-free interval of 24 months, five-year Kaplan-Meier estimated survival at diagnosis increased from 74.2 to 91.0% in stage I-II, from 31.1 to 65.3% in stage III, and from 6.3 to 34.1% in stage IV. In multivariable Cox regression models addressing CSM, systemic therapy (Hazard Ratio [HR]: 0.47, P = 0.020), nephrectomy (HR: 0.37, P < 0.001) and combination of both (HR: 0.28, P < 0.001) exhibited a strong protective effect.

CONCLUSION

Despite its highly aggressive phenotype and dismal survival, CDC is sensitive to nephrectomy and/or systemic therapy. Moreover, even for advanced stage, a more favorable prognosis can be achieved in patients, who benefit of disease-free interval after diagnosis and initial treatment.

Cost-effectiveness model of renal cell carcinoma (RCC) surveillance in hereditary leiomyomatosis and renal cell carcinoma (HLRCC)

PURPOSE

To determine the cost-effectiveness of annual renal imaging surveillance (RIS) in hereditary leiomyomatosis and renal cell cancer (HLRCC). HLRCC is associated with a 21% risk to age 70 years of RCC. Presentations with advanced renal cell cancer (RCC) are associated with poor outcomes whereas RIS detects early-stage RCC; however, evidence for the cost-effectiveness of RIS is lacking.

METHODS

We developed a decision-analytic model to compare, at different age starting points (11 years, 18 years, 40 years, 60 years), the costs and benefits of lifetime contrast-enhanced renal MRI surveillance (CERMRIS) vs no surveillance in HLRCC. Benefits were measured in life-years gained (LYG), quality-adjusted life years (QALYs) and costs in British Pounds Sterling (GBP). Net monetary benefit (NMB) was calculated using a cost-effectiveness threshold of £20 000/QALY. One-way sensitivity and probabilistic analyses were also performed.

RESULTS

In the base-case 11-year age cohort, surveillance was cost-effective (Incremental_NMB=£3522 (95% CI -£2747 to £7652); Incremental_LYG=1.25 (95% CI 0.30 to 1.86); Incremental_QALYs=0.29 (95% CI 0.07 to 0.43)] at an additional mean discounted cost of £2185/patient (95% CI £430 to £4144). Surveillance was also cost-effective in other age cohorts and dominated a no surveillance strategy in the 40 year cohort [Incremental_NMB=£12 655 (95% CIs -£709 to £21 134); Incremental_LYG=1.52 (95% CI 0.30 to 2.26); Incremental_QALYs=0.58 (95% CI 0.12 to 0.87) with a cost saving of £965/patient (95% CI -£4202 to £2652).

CONCLUSION

Annual CERMRI in HLRCC is cost-effective across age groups modelled.

Conditional survival of metastatic clear cell renal cell carcinoma: How prognosis evolves after cytoreductive surgery of primary tumor

Introduction

Cytoreductive surgery is one of the recommended treatments for metastatic renal cell carcinoma, while the prognostic information of these patients treated with cytoreductive surgery is limited. In this study, we aimed to investigate the survival profiles based on conditional survival (CS) estimates in metastatic clear cell renal cell carcinoma (mccRCC) patients treated with cytoreductive surgery of primary tumor.

Methods and materials

We identified and extracted mccRCC patients from the Surveillance, Epidemiology, and End Results database. We used Kaplan–Meier method to perform CS analyses. A multivariate Cox regression model was applied to explore the changes of well‐known prognostic factors.

Results

Conditional overall survival (COS) and conditional cancer‐specific survival (CCSS) improved increasingly at all periods of survivorships compared to survival estimates at baseline in overall population of mccRCC. The 36‐month COS improved by 3.3%–6.4% given per 12 additional months of survivorships and the CCSS improved significantly from 45.1% (95% CI 42.8–47.3) at 12 months to 67.1% (95% CI 62.0–71.7) at 60 months. Much more survival gain was observed in patients with advanced disease. Furthermore, the prognostic significance of age and pathological factors diminished and even disappeared in a long‐term survivorship.

Conclusions

Conditional overall survival and CCSS improved with time dynamically in mccRCC patients treated with cytoreductive surgery of primary tumor. Patients with advanced disease achieved significant survival gain and even could harvest a better prognosis given that the time of survivorship exceeds a certain period. Our findings could provide valuable and practical data for patient counseling and surveillance strategy making.

Conditional Survival of Patients With Nonmetastatic Renal Cell Carcinoma: How Cancer-Specific Mortality Changes After Nephrectomy

BACKGROUND

Conditional survival (CS) may reveal important differences in cancer-specific mortality (CSM) among patients with nonmetastatic renal cell carcinoma (nmRCC). This study assessed CS according to T and N stages in patients treated surgically for nmRCC.

PATIENTS AND METHODS

Within the SEER database (2001-2015), all patients with nmRCC treated with either partial or radical nephrectomy were identified. CSM-free estimates according to T and N stage and substage groupings (pT1aN0-pT4N0 and pTanyN1) and multivariable Cox regression models with adjustment for Fuhrman grade and histologic subtype were assessed.

RESULTS

According to T and N stage and substage groupings, the following patients were included in the study: 35,966 (46.2%) with pT1aN0 disease; 18,858 (24.2%) with pT1bN0; 5,977 (7.7%) with pT2aN0; 2,511 (3.2%) with pT2bN0; 11,839 (15.2%) with pT3aN0; 1,037 (1.3%) with pT3b-cN0; 402 (0.5%) with pT4N0; and 1,302 (1.7%) with pTanyN1. Conditional CSM-free survival estimates were 98.2% at 1 year versus 98.0% at 10 years of event-free follow-up for patients with pT1aN0 disease, relative to baseline. Conversely, pT4N0/pTanyN1 conditional CSM-free survival estimates were 55.8% at 1 year versus 77.9% at 8 years of event-free follow-up. Attrition due to mortality was highest in patients with pT4N0/pTanyN1 disease. In multivariable Cox regression analyses, T stage, tumor grade, and histologic subtype represented independent predictors, but no interactions were identified.

CONCLUSIONS

Tumor stage and its substages represent extremely important determinants of prognosis after lengthy event-free follow-up. The recorded observations have critical importance for physicians regarding patient follow-up and counseling.

Conditional disease-free survival in high-risk renal cell carcinoma treated with sunitinib

BACKGROUND

Disease-free survival (DFS) did not reflect accurate individual prognosis after initial diagnosis. As conditional DFS (CDFS) could provide dynamic prognostic information, we evaluated CDFS in these patients treated with or without sunitinib.

RESULTS

A total of 1329 patients with median follow-up 6.54 years were enrolled. CDFS improved continuously with disease-free survivorship increasing in both sunitinib and placebo group with minimal difference. In placebo arm, the CDFS of surviving to five year after living 1, 2, 3, and 4 years were 65%, 78%, 87%, and 95% (observed 5-year DFS: 51%). Dynamic changes of HR showed adjuvant sunitinib decrease relapse risks during the first 1.5 years after surgery (P < 0.03).

CONCLUSIONS

Our study provided contemporary data of CDFS and change of relapse HR in high-risk ccRCC patients after adjuvant sunitinib or placebo. The remarkable improvement in CDFS highlighted the importance of disease-free interval as a strong indicator in patient counseling and surveillance planning.

MATERIALS AND METHODS

The primary end point was CDFS and the second end point was smooth hazard ratios (HR) for the prediction of relapses. The differences of conditional survival were compared with the calculation of d value.

Stage-specific conditional survival in renal cell carcinoma after nephrectomy

OBJECTIVES

Conditional survival (CS) represents the probability that a cancer patient will survive some additional number of years, given that the patient has already survived for a certain period of time. CS estimates, therefore, serve as better measures of survival probability compared to standard estimates as they incorporate patient survivorship. Stage-specific CS has not been widely investigated in the context of renal cell carcinoma (RCC) after nephrectomy. We aimed to examine this phenomenon.

MATERIALS AND METHODS

We analyzed retrospective data on a population-based cohort of 87,225 surgically-treated RCC patients extracted from the Surveillance, Epidemiology, and End Results database (2004-2015) and on a similar validation cohort of 1,642 patients from our institution (1995-2015). 5-year cancer-specific CS estimates stratified by stage were obtained using the Kaplan-Meier method. Multivariable Cox regression analyses were performed to evaluate the possible variation in risk of cancer-specific mortality by stage at nephrectomy and with increasing postoperative survivorship.

RESULTS

5-year cancer-specific survival rates at time of nephrectomy for stage I, II, III, and IV patients in the population-based cohort were 97.4%, 89.9%, 77.9%, and 26.7%, respectively. Improvement in 5-year CS was mainly observed in surviving patients with advanced-stage disease; given 1, 2, 3, 4, and 5 years of survivorship after nephrectomy, the subsequent 5-year cancer-specific survival rates were, respectively, 79.3% (+1.8% increase over previous survival probability), 81.3% (+2.5%), 83.3% (+2.5%), 84.3% (+1.2%), and 85.1% (+1.0%) for stage III, and 34.6% (+29.6%), 42.5% (+22.8%), 49.0% (+15.3%), 55.7% (+13.7%), and 58.6% (+5.2%) for stage IV. A similar trend was established in the validation cohort. Findings were confirmed upon multivariable analyses.

CONCLUSIONS

CS after nephrectomy for RCC varies dramatically by stage of disease. Gains in CS over time occur primarily among patients with advanced-stage disease. Stage-specific CS estimates can help urologists better plan postoperative surveillance for RCC patients.

Changes in conditional net survival and dynamic prognostic factors in patients with newly diagnosed metastatic prostate cancer initially treated with androgen deprivation therapy

BACKGROUND

The purpose of this study was to identify predictive factors associated with conditional net survival in patients with metastatic hormone-naive prostate cancer (mHNPC) initially treated with androgen deprivation therapy (ADT).

METHODS

At nine hospitals in Tohoku, Japan, the medical records of 605 consecutive patients with mHNPC who initially received ADT were retrospectively reviewed. The Pohar Perme estimator was used to calculate conditional net cancer-specific survival (CSS) and overall survival (OS) for up to 5 years subsequent to the diagnosis. Using multiple imputation, proportional hazard ratios for conditional CSS and OS were calculated with adjusted Cox regression models.

RESULTS

During a median follow up of 2.95 years, 208 patients died, of which 169 died due to progressive prostate cancer. At baseline, the 5-year CSS and OS rates were 65.5% and 58.2%, respectively. Conditional 5-year net CSS and OS survival gradually increased for all the patients. In patients given a 5-year survivorship, the conditional 5-year net CSS and OS rates improved to 0.906 and 0.811, respectively. Only the extent of disease score (EOD) ≥2 remained a prognostic factor for CSS and OS up to 5 years; as survival time increased, other variables were no longer independent prognostic factors.

CONCLUSIONS

The conditional 5-year net CSS and OS in patients with mHNPC gradually increased; thus, the risk of mortality decreased with increasing survival. The patient's risk profile changed over time. EOD remained an independent prognostic factor for CSS and OS after 5-year follow-up. Conditional net survival can play a role in clinical decision-making, providing intriguing information for cancer survivors.

Prognosis of Young Survivors of Gastric Cancer in China and the U.S.: Determining Long-Term Outcomes Based on Conditional Survival

BACKGROUND

Young survivors of gastric cancer (GC) have better prognoses than elderly patients, yet their disease-specific survival (DSS) has received little attention.

PATIENTS AND METHODS

Data on young patients (aged ≤40 years) with GC undergoing resections at three Chinese institutions (n = 542) and from the SEER database (n = 533) were retrospectively analyzed. Three-year conditional disease-specific survival (CS3) was assessed. The effects of well-known prognostic factors over time were analyzed by time-dependent Cox regression.

RESULTS

Overall, young Chinese patients with GC had a better 5-year DSS than U.S. patients (62.8% vs. 54.1%; p < .05). The disease-specific mortality likelihood of the entire cohort was not constant over time, with most deaths occurring during the first 3 years after surgery but peaking at 1 and 2 years in China and the U.S., respectively. Based on 5-year survivorship, the CS3 rates of both groups were similar (90.9% [U.S.] vs. 91.5% [China]; p > .05). Cox regression showed that for Chinese patients, site, size, T stage, and N stage were independent prognostic factors at baseline (p < .05). For U.S. patients, grade, T stage. and N stage significantly affected DSS at baseline (p < .05). In both groups, only T stage continuously affected DSS within 3 years after gastrectomy. However, for both groups, the initial well-known prognostic factors lost prognostic significance after 5 years of survival (all p > .05). Although the 5-year DSS rates of young Chinese patients with T3 and T4a disease were significantly better than those of young U.S. patients, in each T stage, the CS3 of both regions trended toward consistency over time.

CONCLUSION

For young patients with GC, the factors that predict survival at baseline vary over time. Although the initial 5-year DSS is heterogeneous, insight into conditional survival will help clinicians evaluate the long-term prognoses of survivors while ignoring population differences.

IMPLICATIONS FOR PRACTICE

With the increasing number of young survivors of gastric cancer (GC), it is essential for clinicians to understand the dynamic prognosis of these patients. Based on large data sets from China and the U.S., this study found that the prognostic factors that predict survival for young patients with GC at baseline vary over time. Although the initial 5-year disease-specific survival is heterogeneous, insight into conditional survival will help clinicians evaluate the long-term prognoses of survivors while ignoring population differences. This knowledge may be more effective in helping young patients with GC to manage future uncertainties, especially when they need to make important life plans.

Time trends in service provision and survival outcomes for patients with renal cancer treated by nephrectomy in England 2000-2010

OBJECTIVE

To describe the temporal trends in nephrectomy practice and outcomes for English patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

Adult RCC nephrectomy patients treated between 2000 and 2010 were identified in the National Cancer Data Repository and Hospital Episode Statistics, and followed-up until date of death or 31 December 2015 (n = 30 763). We estimated the annual frequency for each nephrectomy type, the hospital and surgeon numbers and their case volumes. We analysed short-term surgical outcomes, as well as 1- and 5-year relative survivals.

RESULTS

Annual RCC nephrectomy number increased by 66% during the study period. Hospital number decreased by 24%, whilst the median annual hospital volume increased from 10 to 23 (P < 0.01). Surgeon number increased by 27% (P < 0.01), doubling the median consultant number per hospital. The proportion of minimally invasive surgery (MIS) nephrectomies rose from 1% to 46%, whilst the proportion of nephron-sparing surgeries (NSS) increased from 5% to 16%, with 29% of all T1 disease treated with partial nephrectomy in 2010 (P < 0.01). The 30-day mortality rate halved from 2.4% to 1.1% and 90-day mortality decreased from 4.9% to 2.6% (P < 0.01). The 1-year relative survival rate increased from 86.9% to 93.4%, whilst the 5-year relative survival rate rose from 68.2% to 81.2% (P < 0.01). Improvements were most notable in patients aged ≥65 years and those with T3 and T4 disease.

CONCLUSIONS

Surgical RCC management has changed considerably with nephrectomy centralisation and increased NSS and MIS. In parallel, we observed significant improvements in short- and long-term survival particularly for elderly patients and those with locally advanced disease.

Conditional survival of patients with small renal masses undergoing active surveillance

OBJECTIVES

To determine conditional survival for patients with small renal masses (SRMs) undergoing active surveillance (AS).

MATERIALS AND METHODS

Patients were enrolled in a prospective AS protocol at our institution between May 2005 and January 2016. Patients with SRMs ≤4 cm with serial cross-sectional imaging available in-house for review were included. Overall survival (OS) was estimated using the Kaplan-Meier method and modelled via Cox proportional hazards models. The primary endpoints analysed were the conditional probability of survival and tumour growth over time. Landmark analysis was used to evaluate survival outcomes beyond the 2-year mark after the initial scan. The relative conditional survival of patients on AS was compared to those undergoing partial nephrectomy (PN) using inverse probability of treatment weighting.

RESULTS

A total of 272 patients were included in this analysis. The mean initial SRM size was 1.74 ± 0.77 cm, and the mean mass size closest to the 2-year mark was 1.97 ± 0.83 cm. The likelihood of continued survival to 5 years improved after the 2-year landmark. Patients with masses <3 cm who survived the first 2 years on AS had a 0.84-0.85 chance of surviving to 5 years, and if they survived 3 years, the probability of surviving to 5 years improved to 0.91. A slow tumour growth (β: 0.12; P < 0.001) with parallel growth rates was found for tumours <3 cm. Patients on AS and those who underwent PN had similar OS for ~7 years, beyond which PN demonstrated a trend of lower risk of death compared with AS (hazard ratio 0.57; P = 0.07).

CONCLUSIONS

The conditional survival probability of patients with SRMs <3 cm on AS increased after 2 years. This information may prove useful to urologists and patients who are considering continuing AS vs intervention after the first 2 years on AS.

Changeable Conditional Survival Rates and Associated Prognosticators in Patients with Metastatic Renal Cell Carcinoma Receiving First Line Targeted Therapy

PURPOSE

In this study we evaluated conditional survival probabilities in patients with metastatic renal cell carcinoma who underwent first line tyrosine kinase inhibitor therapy. We also identified predictors of conditional survival with time.

MATERIALS AND METHODS

We retrospectively reviewed clinical data on 1,659 individuals with metastatic renal cell carcinoma in the Korean Renal Cancer Study Group database, of whom the records of 1,131 were finally analyzed. The primary end point was conditional overall survival. Kaplan-Meier survival analysis was used to calculate conditional overall survival probabilities using the formula, conditional survival (α│β) = S(α + β)/S(β), indicating the likelihood of additional α years survivorship in person who has already survived for β years after initial therapy. S(χ) represents the actual survival rate. Multivariate Cox regression model was used to identify predictors of conditional survival with time.

RESULTS

Six, 12, 18, 24 and 36-month conditional overall survival gradually increased in patients at all additional survival times after initial treatment compared to patient baseline survival estimations. While the actual overall survival rate decreased with time, the 36-month conditional overall survival rate was calculated as 7.3% higher in patients who had already survived 36 months compared to baseline estimations at the time of initial tyrosine kinase inhibitor treatment. Furthermore, predictors of conditional overall survival changed with time. Only previous metastasectomy remained a key prognosticator of conditional overall survival until 36 months of survival following initial tyrosine kinase inhibitor treatment.

CONCLUSIONS

Conditional survival improved with time after initial tyrosine kinase inhibitor treatment in patients with metastatic renal cell carcinoma. Our study offers valuable information for practical survival estimations and relevant prognosticators in patients with metastatic renal cell carcinoma who receive first line tyrosine kinase inhibitor.

Conditional disease-free survival among patients with breast cancer

Conditional disease-free survival (CDFS) reflects changes over time. Because traditional disease-free survival (DFS) is estimated from the date of diagnosis, it is limited in the ability to predict risk of recurrence in patients who have been disease free. In this study, we determined CDFS of breast cancer patients and estimated the prognostic factors for DFS.We retrospectively reviewed clinical data of 7587 consecutive patients who underwent curative surgery for breast cancer between January 2004 and December 2013 at Samsung Medical Center. Univariate and multivariate analyses were performed to identify risk factors for DFS, which was computed using the Kaplan-Meier method. CDFS rates were based on cumulative DFS estimates.Median follow-up duration was 20.59 months. Three-year DFS was 93.46% at baseline. Three-year CDFS survival estimates for patients who had been disease free for 1, 2, 3, 4, and 5 years after treatment were calculated as 92.84%, 92.37%, 93.03%, 89.41%, and 79.64%, respectively. Three-year CDFS increased continuously each year after 1 year of DFS in hormone receptor (HR)-negative patients but decreased each year in HR-positive patients.In HR-positive patients who are disease free after 3 years, continuous care including surveillance and metastases workup should be considered, although this is not recommended in the current guidelines. On the other hand, the social costs may be reduced in HR-negative patients by extending the surveillance interval. Further studies are needed to identify indicators of DFS prognosis in breast cancer patients.

Conditional Disease-free Survival After Radical Prostatectomy: Recurrence Risk Evolution Over Time

OBJECTIVE

To assess changes in conditional disease-free survival (DFS) rates after radical prostatectomy (RP) and how the impact of well-known prognostic factors evolves over time.

MATERIALS AND METHODS

There were 2813 patients treated with RP and postoperatively followed with clinical and prostate-specific antigen assessments. Estimation of conditional survival (CS) probabilities used the Kaplan-Meier method. Multivariable Cox regression model was used to calculate proportional hazard ratios for prediction of DFS after stratification by prognostics characteristics.

RESULTS

The 5-year DFS rate was 71.2%. The DFS rate 5 years after RP increased to 77.4% (+8.7%), 82.1% (+15.3%), 88.0% (+23.6%), and 94.0% (+32.0%) for patients surviving without recurrence 1, 2, 3, and 4 years after RP, respectively. This represented a relatively stable survival gain per survived year ranging from 5.6% to 8.7%. The conditional 5-year DFS improves mainly for disease-free surviving patients with adverse pathologic factors. Among patients with pT3b-4 disease, the probability of surviving without recurrence to year 5 increased from 20.7% at the time of presentation to 78.9% for patients surviving 4 years without recurrence (+281%) as compared to +12.5% in pT2 disease. The impact of Gleason score and pT stage on CS estimates remained stable over time. Findings were confirmed upon multivariable analyses.

CONCLUSION

The period elapsed from RP is associated with DFS. The risk of recurrence decreases with increasing survivorship, mainly in patients with adverse pathologic factors. CS can provide relevant information for clinicians and patients giving an update of their risk of subsequent recurrence.

Conditional Survival and Associated Prognostic Factors in Patients with Upper Tract Urothelial Carcinoma after Radical Nephroureterectomy: A Retrospective Study at a Single Institution

Purpose

The purpose of this study is to evaluate the changes of conditional survival (CS) probabilities and to identify the prognostic parameters that significantly affect CS over time post-surgery in upper tract urothelial carcinoma (UTUC) patients.

Materials and Methods

A total of 330 patients were examined in the final analysis. Primary end point was conditional cancer-specific survival (CSS), overall survival (OS), and intravesical recurrence-free survival (IVRFS) after surgery. The Kaplan-Meier method was used for calculation of CS. Cox regression hazard ratio model was used to determine the predictors of CS.

Results

UTUC patients who had already survived 5 years after radical nephroureterectomy had a more favorable CS probability in all given survivorships compared to those with shorter survival times. Patients with unfavorable pathologic features showed a higher increment of 5-year conditional CSS and OS compared to their counterparts. For 5-year conditional CSS, several factors, including high-grade tumor, lymphovascular invasion, and tumor location showed significant association with risk elevation over time. Only age remained as a predictor of 5-year conditional OS with increased risk in all given survivorships. For 5-year IVRFS, no variables remained as significant predictive factors over time after surgery.

Conclusion

Our study provides valuable information for practical survival estimation and relevant prognostic factors for patients with UTUC after surgery.

Evaluation of ABO blood group as a prognostic marker in renal cell carcinoma (RCC)

OBJECTIVE

To evaluate ABO blood group as a prognostic marker in patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

This retrospective study included 556 consecutive patients who underwent surgery for RCC at a single institution. The associations of ABO blood group with clinical and pathological variables were assessed using Kruskal-Wallis and chi-squared tests. The impact on overall survival (OS) and RCC-specific survival (RCC-SS) was analysed using univariable and multivariable Cox proportional hazards regression models.

RESULTS

Blood group O was associated with the absence of lymph node metastases (P = 0.034) and the presence of bilateral RCC (P = 0.017). No associations with age, gender, body mass index, Charlson comorbidity index, T stage, M stage, grade and histological subtype were observed. In univariable and multivariable survival analysis, ABO blood group was not associated with OS and RCC-SS.

CONCLUSIONS

In the present study, ABO blood group was not linked with RCC prognosis. Blood group O may be associated with the absence of lymph node metastases and the presence of bilateral RCC. External validation in larger cohorts is necessary.

Conditional survival after radical cystectomy for bladder cancer: evidence for a patient changing risk profile over time

BACKGROUND

Standard survival statistics do not take into consideration the changes in the weight of individual variables at subsequent times after the diagnosis and initial treatment of bladder cancer.

OBJECTIVE

To assess the changes in 5-yr conditional survival (CS) rates after radical cystectomy for bladder cancer and to determine how well-established prognostic factors evolve over time.

DESIGN, SETTING, AND PARTICIPANTS

We analyzed data from 8141 patients treated with radical cystectomy at 15 international academic centers between 1979 and 2012.

INTERVENTIONS

Radical cystectomy and pelvic lymph node dissection.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Conditional cancer-specific survival (CSS) and overall survival (OS) estimates were calculated using the Kaplan-Meier method. The multivariable Cox regression model was used to calculate proportional hazard ratios for the prediction of mortality after stratification by clinical characteristics (age, perioperative chemotherapy status) and pathologic characteristics (pT stage, grade, lymphovascular invasion, pN stage, number of nodes removed, margin status). The median follow-up was 32 mo.

RESULTS AND LIMITATIONS

The 5-yr CSS and OS rates were 67.7% and 57.5%, respectively. Given a 1-, 2-, 3-, 5- and 10-yr survivorship, the 5-yr conditional OS rates improved by +5.6 (60.7%), +8.4 (65.8%), +7.6 (70.8%), +3.0 (72.9%), and +1.9% (74.3%), respectively. The 5-yr conditional CSS rates improved by +5.6 (71.5%), +9.8 (78.5%), +7.9 (84.7%), +7.2 (90.8%), and 5.6% (95.9%), respectively. The 5- and 10-yr CS improvement was primarily noted among surviving patients with advanced stage disease. The impact of pathologic parameters on CS estimates decreased over time for both CSS and OS. Findings were confirmed on multivariable analyses. The main limitation was the retrospective design.

CONCLUSIONS

CS analysis demonstrates that the patient risk profile changes over time. The risk of mortality decreases with increasing survivorship. The CS rates improve mainly in the case of advanced stage disease. The impact of prognostic pathologic features decreases over time and can disappear for long-term CS.