Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines.
OBJECTIVE
The National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). Herein, we assess the ability of the guidelines to capture RCC recurrences and determine the duration of surveillance required to capture 90%, 95%, and 100% of recurrences.


METHODS
We evaluated 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared.


RESULTS
At a median follow-up of 9.0 years (interquartile range, 5.7 to 14.4 years), a total of 1,088 patients (29.8%) experienced a recurrence. Of these, 390 recurrences (35.9%) were detected using 2013 NCCN recommendations, 742 recurrences (68.2%) were detected using 2014 NCCN recommendations, and 728 recurrences (66.9%) were detected using AUA recommendations. All protocols missed the greatest amount of recurrences in the abdomen and among pT1Nx-0 patients. To capture 95% of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were $1,228.79 using 2013 NCCN, $2,131.52 using 2014 NCCN, and $1,738.31 using AUA guidelines. However, if 95% of LR-partial recurrences were captured, costs would total $9,856.82.


CONCLUSIONS
If strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.
All authors: Mayo Clinic, Rochester, MN.
Suzanne B
SB
Stewart
All authors: Mayo Clinic, Rochester, MN.
R Houston
RH
Thompson
All authors: Mayo Clinic, Rochester, MN.
Sarah P
SP
Psutka
All authors: Mayo Clinic, Rochester, MN.
John C
JC
Cheville
All authors: Mayo Clinic, Rochester, MN.
Christine M
CM
Lohse
All authors: Mayo Clinic, Rochester, MN.
Stephen A
SA
Boorjian
All authors: Mayo Clinic, Rochester, MN. leibovich.bradley@mayo.edu.
Bradley C
BC
Leibovich
D000368:Aged; D002292:Carcinoma, Renal Cell / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D019983:Guideline Adherence; D017048:Health Care Costs; D006801:Humans; D007680:Kidney Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D017410:Practice Guidelines as Topic; D013997:Time Factors