Toward greater adoption of minimally invasive and nephron-sparing surgical techniques for renal cell cancer in the United States

Abstract

Purpose: To examine national, population-based utilization trends of nephron-sparing and minimally invasive techniques for the surgical management of patients with adult renal cell cancer (RCC) in the United States.

Methods: Linked data from the National Cancer Institute׳s Patterns of Care studies and the Area Health Resource File were used to evaluate trends of nephron-sparing and minimally invasive techniques in a sample of 1,110 patients newly diagnosed with American Joint Committee on Cancer stages I-II RCC, in 2004 and 2009, who underwent surgery. Descriptive statistics were used to assess patterns of surgery between 2004 and 2009. Multivariable logistic regression analyses were used to evaluate the associations between demographic, clinical, hospital, and area-level health care characteristics with surgery utilization, stratified by the subset of patients who were potentially eligible for partial nephrectomy (PN) vs. radical nephrectomy (RN) and laparoscopic RN (LRN) vs. open RN, respectively.

Results: Between 2004 and 2009, PN use among stage I patients with tumors≤7cm increased from 29% to 41%, respectively (P = 0.22). Among patients with stage I tumors≤4cm, use of PN significantly increased from 43% in 2004 to 55% in 2009 (P≤0.05). Among patients with stage I tumors>4 to 7cm, laparoscopic partial nephrectomy increased from 8% to 15%, whereas LRN increased from 38% to 69%, between 2004 and 2009 (P = 0.07). Significant increases in LRN use were observed for both stage I (from 43% in 2004 to 58% in 2009; P≤0.05) and stage II patients (from 16% in 2004 to 47% in 2009; P≤0.01). Patients diagnosed at an older age, with larger tumors, non-clear cell RCC and who did not receive treatment in a hospital with residency training were significantly less likely to receive PN vs. RN; whereas, those diagnosed in 2009 with stage I disease were significantly more likely to receive LRN vs. open RN.

Conclusions: This study highlights a significant shift toward increased use of nephron-sparing and minimally invasive surgical techniques to treat patients with RCC in the United States. Our findings are among the first population-based reports in which most eligible patients with RCC received PN over RN. In light of the long-standing evidence on the improved patient outcomes, future investigation is warranted to identify the barriers to increased adoption of these nephron-sparing and minimally invasive approaches.

Keywords: Laparoscopic radical nephrectomy; Nephron-sparing surgery; Open radical nephrectomy; Partial nephrectomy; Patterns of care; Radical nephrectomy; Renal cell cancer.

Figure 1. Percentage of participants receiving partial versus radical nephrectomy, by tumor size and year of diagnosis

Notes: Estimates are based on patients diagnosed with AJCC stage I tumors 7cm or less, who received surgery of the primary tumor site within 12 months following diagnosis, who underwent partial nephrectomy (including partial or subtotal nephrectomy) or radical nephrectomy (including complete/total/simple nephrectomy and radical nephrectomy). Percentages are presented among all patients with AJCC stage I tumors 7cm or less, among those with stage I tumors 4cm or less only, and those with stage I tumors >4-7cm only, separately. Data for 2004 are weighted to SEER 2006, whereas data for 2009 are weighted to SEER 2011. *p≤0.05.

Figure 2. Percentage of participants receiving open partial, laparoscopic partial, open radical and laparoscopic radical nephrectomy, by tumor size and year of diagnosis

Notes: Estimates are based on patients diagnosed with AJCC stage I tumors 7cm or less, who received surgery of the primary tumor site within 12 months following diagnosis, who underwent partial nephrectomy (including partial or subtotal nephrectomy) or radical nephrectomy (including complete/total/simple nephrectomy and radical nephrectomy). Individuals with missing information on type of nephrectomy (laparoscopic or open) were excluded. Percentages are presented among all patients with AJCC stage I tumors 7cm or less, among those with stage I tumors 4cm or less only, and those with stage I tumors >4-7cm only, separately. Data for 2004 are weighted to SEER 2006, whereas data for 2009 are weighted to SEER 2011.

Figure 3. Percentage of participants receiving laparoscopic versus open radical nephrectomy, by tumor stage at diagnosis and year of diagnosis

Notes: Estimates are based on the number of patients diagnosed with tumor stages I-II, who received surgery of the primary tumor site within 12 months following diagnosis, who received radical nephrectomy via laparoscopic or open surgical techniques. Percentages are presented among all patients with tumor stages I-II, among those with stage I tumors and those with stage II tumors, separately. *p≤0.05. **p≤0.01