Kidney cancer specialists reported that the use of radical nephrectomy for small renal masses remains “alarmingly high,” particularly among older patients. Between 1995 and 2005, the use of radical nephrectomy decreased by 50 percent, but most of the decline was offset by a dramatic increase in the rate of laparascopic radical nephrectomies.
Use of laparascopic techniques to remove small renal masses increased by 35 percent overall. Nephron-sparing surgery, on the other hand, increased by 15.5 percent. These findings were presented at the American Urological Association meeting.
Marc Smaldone, MD, of Fox Chase Cancer Center in Philadelphia reported that in 2005, 77 percent of patients were treated with radical nephrectormy, either open or laparoscopic.
Investigators reported in another study that older patients were significantly more likely to have radical nephrectomy for small renal tumors compared with their younger counterparts.
James McKiernan, MD, of Columbia University in New York, said that this disparity is most common in patients with the smallest masses. Over a third of small renal masses are less than 4cm, and incidental discovery of small masses has increased 244% since 1982. The dramatic rise in the detection has coincided with the aging of the American population.
The AUA clinical guidelines for management of small renal masses emphasize disease control, nephron preservation, and use of minimally invasive techniques whenever appropriate. Noting a potential to reduce the risks of chronic kidney disease, cardiovascular disease, and mortality, the guidelines cite nephron-sparing surgery as the reference standard.
Investigators reviewed the NCI Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database from 1995 to 2005. The team identified all patients treated for small renal masses and grouped the patients by type of surgical procedure: open radical nephrectomy, open partial nephrectomoy, laparoscopic radical nephrectommy, and laparascopic partial nephrectomy. In 1995, radical nephrectomy accounted for 93% of all the procedures, 87% of which involved open surgery. In 2005, radical nephrectomy’s total share of procedures had declined to 73%, more than half (40.8%) performed laparoscopically. During this time, the rate of open partial nephrectomy increased from 6.7% to 13.5%, and use of laparoscopic partial nephrectomy increased from 0.6% to 9.3%.
Mckiernan reported from a review of SEER data that identified 18,000 patients who had small (4 cm or less) localized tumors between 1998 and 2007 that the preference for radical versus nephron-sparing surgery has become even more pronounced among older patients. The study analyzed trends in the use of radical nephrectomy by age and tumor size. Two thousand seven hundred and thirty three patients were 27 or older, and 15,312 were younger than 75.
Overall, radical nephrectomy was the treatment of choice for both age groups, but was significantly greater among older patients: 66% of all surgical procedures compared with 59% among younger patients. Stratification by tumor size showed that the age-related difference in use of radical nephrectomy increased as tumor size decreased. Although use of radical nephrectomy decreased with tumor size in both age groups, the magnitude of the difference between the groups increased.