Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management.
OBJECTIVE
To compare overall and cancer-specific survival (CSS) of patients who undergo nonsurgical management (NSM), partial nephrectomy (PN), and radical nephrectomy (RN). NSM is being increasingly used for older patients with early-stage kidney cancer and competing risks of death. However, survival is poorly characterized for this approach compared with surgery with PN or RN.


METHODS
The Surveillance, Epidemiology and End Results-Medicare database from 1995 to 2007 was used to identify patients aged 65 years or older diagnosed with localized T1a kidney cancer treated with PN, RN, or NSM. We used Cox proportional hazards regression, Fine and Gray competing risks regression, and propensity score matching to adjust for patient and tumor characteristics.


RESULTS
Of 7177 Medicare beneficiaries meeting the inclusion criteria, 754 (10.5%) underwent NSM, 1849 (25.8%) PN, and 4574 (63.7%) RN, with 436 (57.8%), 389 (21.0%), and 1598 (34.9%) patients dying from any cause, respectively, at a median follow-up of 56 months. Overall survival favored PN and RN compared with NSM (hazard ratio [95% CI]: 0.40 [0.34-0.46] and 0.50 [0.45-0.56], respectively) as did CSS (hazard ratio [95% CI]: 0.42 [0.27-0.64] and 0.62 [0.46-0.85], respectively). However, there was no difference in CSS between any 2 treatment groups for younger patients (<75 years), whereas there was an excess of kidney cancer deaths for NSM patients aged 75-79 years and an attenuated difference for patients aged 80 years or older.


CONCLUSIONS
NSM was associated with an increased risk of kidney cancer death among Medicare beneficiaries aged 75-79 years. Evolving active surveillance protocols will need to develop robust selection criteria to maximize cancer survival for older patients with kidney cancer.
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD; Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; Biostatistics Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. Electronic address: hitenpatel@jhmi.edu.
Hiten D
HD
Patel
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD.
Max
M
Kates
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD.
Phillip M
PM
Pierorazio
Division of Urology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
Elias S
ES
Hyams
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD.
Michael A
MA
Gorin
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD.
Mark W
MW
Ball
Division of Urologic Surgery, Washington University School of Medicine, Saint Louis, MO.
Sam B
SB
Bhayani
Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD.
Xuan
X
Hui
Biostatistics Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Carol B
CB
Thompson
James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore, MD; Center for Surgical Trials and Outcomes Research, Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, MD.
Mohamad E
ME
Allaf
D000368:Aged; D000369:Aged, 80 and over; D006801:Humans; D007680:Kidney Neoplasms / Q000401:mortality* / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D009367:Neoplasm Staging; D009392:Nephrectomy; D012189:Retrospective Studies; D015996:Survival Rate