A Clinical Decision Aid to Support Personalized Treatment Selection for Patients with Clinical T1 Renal Masses: Results from a Multi-institutional Competing-risks Analysis

Abstract

Background: Personalized treatment for clinical T1 renal cortical masses (RCMs) should take into account competing risks related to tumor and patient characteristics.

Objective: To develop treatment-specific prediction models for cancer-specific mortality (CSM), other-cause mortality (OCM), and 90-d Clavien grade ≥3 complications across radical nephrectomy (RN), partial nephrectomy (PN), thermal ablation (TA), and active surveillance (AS).

Design, setting, and participants: Pretreatment clinical and radiological features were collected for consecutive adult patients treated with initial RN, PN, TA, or AS for RCMs at four high-volume referral centers (2000-2019).

Outcome measurements and statistical analysis: Prediction models used competing-risks regression for CSM and OCM and logistic regression for 90-d Clavien grade ≥3 complications. Performance was assessed using bootstrap validation.

Results and limitations: The cohort comprised 5300 patients treated with RN (n = 1277), PN (n = 2967), TA (n = 476), or AS (n = 580). Over median follow-up of 5.2 yr (interquartile range 2.5-8.7), there were 117 CSM, 607 OCM, and 198 complication events. The C index for the predictive models was 0.80 for CSM, 0.77 for OCM, and 0.64 for complications. Predictions from the fitted models are provided in an online calculator (https://small-renal-mass-risk-calculator.fredhutch.org). To illustrate, a hypothetical 74-yr-old male with a 4.5-cm RCM, body mass index of 32 kg/m², estimated glomerular filtration rate of 50 ml/min, Eastern Cooperative Oncology Group performance status of 3, and Charlson comorbidity index of 3 has predicted 5-yr CSM of 2.9-5.6% across treatments, but 5-yr OCM of 29% and risk of 90-d Clavien grade 3-5 complications of 1.9% for RN, 5.8% for PN, and 3.6% for TA. Limitations include selection bias, heterogeneity in practice across treatment sites and the study time period, and lack of control for surgeon/hospital volume.

Conclusions: We present a risk calculator incorporating pretreatment features to estimate treatment-specific competing risks of mortality and complications for use during shared decision-making and personalized treatment selection for RCMs.

Patient summary: We present a risk calculator that generates personalized estimates of the risks of death from cancer or other causes and of complications for surgical, ablation, and surveillance treatment options for patients with stage 1 kidney tumors.

Keywords: Ablation; Comorbidity; Competing risks; Decision aid; Nephrectomy; Performance status; Renal cell carcinoma; Shared decision-making; Surveillance; Treatment.

Figure 1:

CONSORT diagram demonstrating patient inclusion criteria across centers, exclusion criteria, and cohort stratification by treatment.

Figure 2:

Cumulative incidence of cancer-specific mortality and other-cause mortality by treatment.

Figure 3:

Example of competing risks predictions including 5-year CSM, OCM, and 90-day complications for (A) a 74-year-old male with a 4.5 cm RCM, BMI of 24 kg/m², eGFR of 60 mL/min, ECOG PS of 0, and CCI of 1 compared to (B) a 74-year-old male with a 4.5 cm RCM, BMI of 32 kg/m², eGFR of 50 mL/min, ECOG PS of 3, and CCI of 3.

Figure 3:

Example of competing risks predictions including 5-year CSM, OCM, and 90-day complications for (A) a 74-year-old male with a 4.5 cm RCM, BMI of 24 kg/m², eGFR of 60 mL/min, ECOG PS of 0, and CCI of 1 compared to (B) a 74-year-old male with a 4.5 cm RCM, BMI of 32 kg/m², eGFR of 50 mL/min, ECOG PS of 3, and CCI of 3.