scholarly journals Determinants of treatment in patients with stage IV renal cell carcinoma

BMC Urology ◽  
2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Christopher S. Hollenbeak ◽  
Eric W. Schaefer ◽  
Justin Doan ◽  
Jay D. Raman
Keyword(s):  
Renal Cell Carcinoma ◽  
Elderly Patients ◽  
Cell Carcinoma ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Stage Iv ◽  
Data Set ◽  
Causes Of Mortality ◽  
Competing Causes ◽  
Metastatic Rcc

Abstract Background Advances in systemic targeted therapies afford treatment opportunities in patients with metastatic renal cell carcinoma (RCC). Elderly patients with metastatic RCC present a subpopulation for consideration owing to competing causes of mortality and benefits seen with new therapeutic agents. We investigate treatment patterns for elderly patients with stage IV RCC and determine factors associated with not receiving treatment. Methods The Surveillance Epidemiology and End Results (SEER) Medicare linked data set contained 949 stage IV RCC patients over age 65 diagnosed between 2007 and 2011. Treatment approach was modeled using multinomial logistic regression. Landmark analysis at 6 months accounted for early death as a potential explanation for no treatment. Results Of the 949 patients with stage IV RCC, 26.2% received surgery and 34.1% received systemic therapy within 6 months of diagnosis. Among our entire cohort, over half (51.2%) had no evidence of receiving surgery or systemic therapy. Among the 447 patients who survived at least 6 months, 26.6% did not receive treatment during this time. Older patients and those with a higher Charlson Comorbidity Index (CCI) had lower odds of being treated with surgery, systemic therapy, or both. Conversely, married patients had higher odds of receiving these therapies. These associations were largely sustained in the 6-month landmark analyses. Conclusions Elderly patients with metastatic RCC present a unique subpopulation for consideration owing to competing causes of mortality. Many elderly patients with stage IV RCC did not receive surgery or systemic therapy up to 6 months from diagnosis. Several clinical and demographic factors were associated with this observation. Further investigation is needed to understand the rationale underlying the underutilization of systemic therapy in elderly patients.

Determinants of treatment in patients with stage IV renal cell carcinoma.

2017 ◽  
Vol 35 (6_suppl) ◽  
pp. 486-486
Author(s):  
Christopher S. Hollenbeak ◽  
Eric W. Schaefer ◽  
Justin Doan ◽  
Jay D. Raman
Keyword(s):  
Renal Cell Carcinoma ◽  
Elderly Patients ◽  
Cell Carcinoma ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Significant Risk ◽  
Stage Iv ◽  
Data Set ◽  
Disease Characteristics ◽  
Landmark Analyses

486 Background: Although there have been significant advances in the detection and treatment of renal cell carcinoma (RCC), many elderly patients—particularly those with stage IV disease—likely receive no treatment. The purpose of this research was to study treatment patterns for elderly patients with stage IV RCC and determine patient and disease characteristics associated with receiving no treatment. Methods: Data from the Surveillance Epidemiology and End Results (SEER) and Medicare linked data set were analyzed. We identified 949 stage IV RCC patients over age 65 years diagnosed between 2007 and 2011. Surgery was identified using Medicare Part A and B claims, and use of systemic therapy was identified from Part D claims in addition to Part A and B claims. Treatment approach, including no treatment, was modeled using multinomial logistic regression controlling for several patient and disease characteristics, allowing us to identify significant risk factors for no treatment. We also performed landmark analyses at 3 and 6 months to account for early death as a potential cause for no treatment. Results: Of the 949 patients with stage IV RCC, 26.2% received surgery and 34.1% received systemic therapy within 6 months of diagnosis. Of 324 patients who received systemic therapy, most received sunitinib (57.1%), temsirolimus (21.3%), or sorafenib (12.3%). Over half of patients (51.2%) had no evidence of receiving surgery or systemic therapy. Of the 618 patients who survived at least 3 months, 38.3% received no treatment within 3 months, and among the 447 patients who survived at least 6 months, 26.6% received no treatment within 6 months. Older patients and those with a higher Charlson Comorbidity Index had lower odds of being treated with surgery, systemic therapy, or both; married patients had higher odds of being treated. These results were largely sustained in 3- and 6-month landmark analyses. Conclusions: Many elderly patients with stage IV RCC did not receive surgery or systemic therapy despite surviving at least 6 months from diagnosis. Several factors appear to be associated with this phenomenon. Further investigation should determine reasons why physicians and/or patients are reluctant to use systemic therapy in patients.

scholarly journals Survival After Surgery for Renal Cell Carcinoma Metastatic to the Spine: Impact of Modern Systemic Therapies on Outcomes

Neurosurgery ◽  
2020 ◽  
Author(s):  
Ganesh M Shankar ◽  
Laura A Van Beaver ◽  
Bryan D Choi ◽  
Muhamed Hadzipasic ◽  
Ahilan Sivaganesan ◽  
...  
Keyword(s):  
Renal Cell Carcinoma ◽  
Cell Carcinoma ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Systemic Disease ◽  
Cohort Analysis ◽  
Spinal Metastases ◽  
Immune Checkpoints ◽  
Metastatic Rcc ◽  
Systemic Therapies

Abstract BACKGROUND Modern medical management of metastatic renal cell carcinoma (RCC) includes therapies targeting tyrosine kinases, growth pathways (mammalian target of rapamycin (mTOR)), and immune checkpoints. OBJECTIVE To test our hypothesis that patients with spinal metastases would benefit from postoperative systemic therapy despite presenting with disease that, in many cases, was resistant to prior systemic therapy. METHODS This is an Institutional Review Board-approved clinical retrospective cohort analysis. A sample of adult patients with RCC metastatic to the spine who underwent operative intervention between January 2010 and December 2017 at 2 large academic medical centers was used in this study. RESULTS We identified 78 patients with metastatic RCC in whom instrumented stabilization was performed in 79% and postoperative stereotactic radiosurgery was performed in 41% of patients. Of patients presenting with weakness or myelopathy, 93% noted postoperative improvement and 78% reported improvement in radicular and axial paraspinal pain severity. Increased overall survival (OS) (913 d (95% CI: 633-1975 d, n = 49) vs 222 d (95% CI: 143-1005 d, n = 29), P = .003) following surgery was noted in patients who received postoperative systemic therapy a median of 80 d (interquartile range 48-227 d) following the surgical intervention. CONCLUSION Postoperative outcomes and palliation of symptoms for metastatic RCC without targeted therapies in this cohort are similar to those reported in earlier series prior to the adoption of these systemic therapies. We observed a significantly longer OS among patients who received modern systemic therapies postoperatively. These findings have implications for the preoperative evaluation of patients with systemic disease who may have been deemed poor surgical candidates prior to the availability of these systemic therapies.

Immune cell repertoire in patients with metastatic renal cell carcinoma: Data from prospective clinical trial.

2015 ◽  
Vol 33 (7_suppl) ◽  
pp. 452-452
Author(s):  
Vijay Damarla ◽  
Paul Elson ◽  
Laura S. Wood ◽  
Sylvia Sybor ◽  
Pat A. Rayman ◽  
...  
Keyword(s):  
Renal Cell Carcinoma ◽  
T Cells ◽  
Cell Carcinoma ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Immune Cell ◽  
Cell Repertoire ◽  
Immune Parameters ◽  
Lower Baseline ◽  
Metastatic Rcc

452 Background: Immune dysfunction is documented in renal cell carcinoma (RCC) patients and likely influences tumor progression. An ongoing prospective trial of observation in metastatic RCC patients prior to systemic therapy is investigating circulating immune cell populations. Methods: Asymptomatic patients with low volume metastatic disease were enrolled and followed until starting initial systemic treatment. Peripheral blood specimens were collected at baseline and again at 3, 6, 9, 12, 16, 20, and 24 months, and then every 6 months until initiating systemic therapy. Immune parameters measured included CD3+ and CD4+ INF-γ producing T cells (INF-γ+ T), CD4+CD25+FoxP3+ regulatory T-cells (Treg), CD33+HLADr-CD15+CD14- neutrophilic myeloid-derived suppressor cells (N-MDSC), monocytic M-MDSC, total MDSC, and lineage-negative MDSC. Similar immune parameters were recorded for treatment-naïve patients prior to immediate systemic therapy (sunitinib or pazopanib, n=34) and healthy volunteers (n=22) on separate IRB-approved protocols. The immune data was analyzed using Wilcoxon rank sum and signed rank tests and proportional hazards models. Results: Forty patients enrolled in the observation study had immunologic data. 25 patients (62%) started systemic therapy, and 15 (38%) continue observation. The observation group had lower baseline levels of MDSC, N-MDSC, M-MDSC, Tregs and higher levels of CD3+INF-γ+ T cells, CD4+ INF-γ+ T cells, and lineage negative MDSC compared to the immediate treatment group, although higher MDSCs and lower Tregs compared to healthy controls. The impact of baseline parameters on the duration of observation revealed that lower Tregs (p=0.003) were associated with a longer time on observation. There were no significant changes in immune parameters of observation patients over the length of observation. Conclusions: Metastatic RCC patients with indolent disease have low levels of Treg and MDSC, and a relatively preserved immune cell repertoire compared to patients requiring immediate therapy. Lower baseline Tregs may be associated with a longer length of observation.

Trends and morbidity for minimally invasive versus open cytoreductive nephrectomy in the management of metastatic renal cell carcinoma.

2018 ◽  
Vol 36 (6_suppl) ◽  
pp. 632-632
Author(s):  
Dimitar V. Zlatev ◽  
Manuel Ozambela ◽  
Keyan Salari ◽  
Ye Wang ◽  
Matthew Mossanen ◽  
...  
Keyword(s):  
Renal Cell Carcinoma ◽  
Blood Transfusion ◽  
Minimally Invasive ◽  
Cell Carcinoma ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Direct Costs ◽  
Cytoreductive Nephrectomy ◽  
Icu Admission ◽  
Metastatic Rcc

632 Background: Cytoreductive nephrectomy (CN) prior to systemic therapy for metastatic renal cell carcinoma (RCC) is recommended in patients with a surgically resectable primary tumor. Traditionally performed as open surgery, the advent of laparoscopic and robotic surgery provides a minimally invasive alternative to CN with a potential for accelerated recovery and earlier initiation of systemic therapy. We sought to compare the trends and morbidity of laparoscopic, robotic, and open CN for patients with metastatic RCC. Methods: Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), we identified 24,145 patients who underwent elective radical nephrectomy for metastatic RCC in the United States between 2003 and 2015. Comparative analysis between laparoscopic, robotic, and open CN was performed with propensity weighting on rates of 90-day complications, blood transfusion, intensive care unit (ICU) admission, prolonged length of stay (LOS), discharge destination, 90-day readmission, operative time, and direct hospital costs. Results: Over the course of the study period, the rates of open CN decreased from 76.7% to 66.4%, laparoscopic CN decreased from 22.3% to 11.4%, and robotic CN increased from 0.6% to 22.1%. Compared to open CN, the laparoscopic approach was associated with a 30% decreased odds of 90-day major complications (OR 0.70, 95% CI 0.50 - 0.97, p < 0.05). Compared to open CN, both laparoscopic and robotic approaches were associated with significantly decreased odds of blood transfusion (OR 0.46 and 0.38, respectively), ICU admission (OR 0.57 and 0.48, respectively), and LOS (OR 0.50 and 0.35, respectively). Direct costs were lowest for laparoscopic CN. Conclusions: Compared to open CN, minimally invasive CN is associated with decreased rates of blood transfusion, ICU admission, and LOS. Laparoscopic CN is additionally associated with decreased major complications and direct costs compared to open CN. When technically feasible, the utilization of minimally invasive CN, especially laparoscopic, may be associated with improved outcomes, decreased costs, and accelerated recovery prior to systemic therapy in patients with metastatic RCC.

scholarly journals Evaluating Overall Survival and Competing Risks of Death in Patients With Localized Renal Cell Carcinoma Using a Comprehensive Nomogram

2010 ◽  
Vol 28 (2) ◽  
pp. 311-317 ◽  
Author(s):  
Alexander Kutikov ◽  
Brian L. Egleston ◽  
Yu-Ning Wong ◽  
Robert G. Uzzo
Keyword(s):  
Renal Cell Carcinoma ◽  
Overall Survival ◽  
Cell Carcinoma ◽  
Kidney Cancer ◽  
Competing Risks ◽  
Tumor Size ◽  
Renal Cell ◽  
Cancer Death ◽  
Causes Of Mortality ◽  
Competing Causes

Purpose Many patients with localized node-negative renal cell carcinoma (RCC) are elderly with competing comorbidities. Their overall survival benefit after surgical treatment is unknown. We reviewed cases in the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the impact of kidney cancer versus competing causes of death in patients with localized RCC and develop a comprehensive nomogram to quantitate survival differences. Methods We identified individuals with localized, surgically treated clear-cell, papillary, or chromophobe RCC in SEER (1988 through 2003). We used Fine and Gray competing risks proportional hazards regressions to predict 5-year probabilities of three competing mortality outcomes: kidney cancer death, other cancer death, and noncancer death. Results We identified 30,801 cases of localized RCC (median age, 62 years; median tumor size, 4.5 cm). Five-year probabilities of kidney cancer death, other cancer death, and noncancer death were 4%, 7%, and 11%, respectively. Age was strongly predictive of mortality and most predictive of nonkidney cancer deaths (P < .001). Increasing tumor size was related to death from RCC and inversely related to noncancer deaths (P < .001). Racial differences in outcomes were most pronounced for nonkidney cancer deaths (P < .001). Men were more likely to die than women from all causes (P < .002). This nomogram integrates commonly available factors into a useful tool for comparing competing risks of death. Conclusion Management of localized RCC must consider competing causes of mortality, particularly in elderly populations. Effective decision making requires treatment trade-off calculations. We present a tool to quantitate competing causes of mortality in patients with localized RCC.

Immune cell repertoire in patients with indolent metastatic renal cell carcinoma.

2013 ◽  
Vol 31 (6_suppl) ◽  
pp. 429-429
Author(s):  
Hui Zhu ◽  
Pat A. Rayman ◽  
Paul Elson ◽  
Sarah Rapp ◽  
Jorge A. Garcia ◽  
...  
Keyword(s):  
Renal Cell Carcinoma ◽  
T Cells ◽  
Cell Carcinoma ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Immune Cell ◽  
Cell Repertoire ◽  
Immune Parameters ◽  
Metastatic Rcc ◽  
Observation Period

429 Background: Immune dysfunction is well documented in renal cell carcinoma (RCC) patients and likely influences tumor progression. An ongoing prospective trial of observation in metastatic RCC patients prior to systemic therapy is investigating circulating immune cell populations. Methods: Asymptomatic patients with low volume metastatic disease are enrolled and followed until starting initial systemic treatment. Peripheral blood specimens are collected at the time of enrollment and again at the time of initiating therapy. The immune parameters measured include CD3+ and CD4+ INF-γ producing T cells (INF-γ+ T), CD4+CD25+FoxP3+ regulatory T-cells (Treg), and CD33+HLADr-CD15+CD14- neutrophilicmyeloid-derived suppressor cells (N-MDSC). Similar immune parameters were recorded for treatment-naïve patients prior to immediate systemic therapy and healthy volunteers on separate IRB-approved protocols. Results: 25 patients are enrolled in the study, of whom 14 started systemic therapy and had immune function analyzed for this report. Patient characteristics included 100% male, median age 74. 13 patients were favorable or intermediate risk by both MSKCC and Heng prognostic criteria; one patient was poor-risk. The median observation period was 13.9 months. The median tumor burden at the time of enrollment was 3.6 cm, which increased 38% during the observation period. As shown in the table below, the observation group had lower levels of Tregand N-MDSC, and higher levels of INF-γ+ T compared to the treatment group. In contrast, the observation group’s INF-γ+ T was similar to that of controls although N-MDSC was elevated. Conclusions: Metastatic RCC patients with indolent disease have low levels of Tregand N-MDSC, and a relatively preserved immune cell repertoire compared to patients requiring immediate therapy. [Table: see text]

Overall survival with or without brain metastases from diagnosis of metastatic renal cell carcinoma.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e16112-e16112
Author(s):  
I. Alex Bowman ◽  
Alana Christie ◽  
Tri Cao Le ◽  
Alisha Bent ◽  
James Brugarolas
Keyword(s):  
Risk Factors ◽  
Renal Cell Carcinoma ◽  
Overall Survival ◽  
Brain Metastases ◽  
Cell Carcinoma ◽  
Surgical Resection ◽  
Systemic Therapy ◽  
Renal Cell ◽  
Local Therapy ◽  
Metastatic Rcc

e16112 Background: Brain metastases (BM) in metastatic renal cell carcinoma (mRCC) have historically been associated with a poor prognosis. We have previously reported improved outcomes for RCC patients diagnosed with brain metastases prior to or during 1st line systemic therapy among patients treated with modern systemic and local therapies. Here we report outcomes in all mRCC patients regardless of the timing of BM diagnosis. Methods: A retrospective database of mRCC patients treated at our institution between 2006 and 2015 was compiled and patients with BM identified. Overall survival (OS) was analyzed by the Kaplan-Meier method from the diagnosis of metastatic RCC, according to BM status and by IMDC risk group. Results: 271 patients with mRCC were identified, including 79 (29.2 %) diagnosed with BM. Clear-cell histology was more common among BM (94.2 v 81.0%, p = 0.01), otherwise patient characteristics were similar. BM were diagnosed prior to systemic therapy (44.3%), or after one or more lines of therapy (one 26.6%, two 13.9%, three 5.1%, four 6.3%, five 3.8%). Among BM patients, 54 (68.4%) received local therapy with stereotactic radiosurgery (SRS) and/or surgical resection, 14 (17.7%) received WBRT alone, and 11 (13.9%) had no CNS-directed treatment. Local therapy consisted of SRS in 43 (54.4%) and surgical resection in 18 (22.8%), with some patients receiving both. Medial OS from metastatic diagnosis for those with BM was not significantly different from those without BM (26.4 v 28.7 mo, p = 0.305). This remained true when analyzed according to IMDC risk factors (see table). Conclusions: OS from the diagnosis of metastatic RCC did not significantly differ with or without BM in a cohort treated with modern systemic and CNS-directed therapies regardless of the timing of BM diagnosis or presence of IMDC risk factors. [Table: see text]

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