title: Temporal trends and factors associated with systemic therapy after cytoreductive nephrectomy: an analysis of the National Cancer Database.
abstract: OBJECTIVE
  We evaluated temporal trends in systemic therapy use in patients undergoing cytoreductive nephrectomy for metastatic renal cell carcinoma. We used data from a large national cancer registry and assessed characteristics associated with the receipt of systemic treatment.
  
  
  METHODS
  We reviewed the NCDB to identify patients with stage IV renal cell carcinoma who underwent cytoreductive nephrectomy between 1998 and 2010. Systemic therapy was defined as immunotherapy and/or chemotherapy, including targeted agents. We evaluated associations between clinicopathological features and receipt of systemic therapy using multivariable logistic regression with generalized estimating equations.
  
  
  RESULTS
  Of 22,409 patients with metastatic renal cell carcinoma treated with cytoreductive nephrectomy 8,830 (39%) received systemic therapy. Use of systemic therapy increased from 32% of cases in 1998 to 49% in 2010 (p < 0.001). After adjustment older patient age (71 years or greater OR 0.36, CI 0.31-0.43), increasing comorbidity count (Charlson comorbidity index 2 or greater OR 0.79, 95% CI 0.68-0.92), papillary histology (OR 0.81, 95% CI 0.71-0.93), sarcomatoid histology (OR 0.88, 95% CI 0.80-0.98), Medicaid (OR 0.61, 95% CI 0.5-0.74), Medicare (OR 0.70, 95% CI 0.62-0.79) and no insurance (OR 0.75, 95% CI 0.63-0.91) were associated with significantly decreased systemic therapy use. Male gender (OR 1.05, 95% CI 1.02-1.08) predicted an increased likelihood of systemic therapy.
  
  
  CONCLUSIONS
  Systemic therapy in patients undergoing cytoreductive nephrectomy has increased with time, coinciding with the introduction of targeted therapies. Nevertheless, still less than half of such patients receive systemic treatment. While the etiology of the lack of treatment is likely multifactorial, the potential health policy implications of disparities in care warrant further investigation.
authors.affiliation: Division of Urologic Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania.
authors.forename: Marc C
authors.initials: MC
authors.lastname: Smaldone
authors.affiliation: Department of Biostatistics and Bioinformatics, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Handorf
authors.affiliation: Department of Urology, Yale University, New Haven, Connecticut.
authors.forename: Simon P
authors.initials: SP
authors.lastname: Kim
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota.
authors.forename: R Houston
authors.initials: RH
authors.lastname: Thompson
authors.affiliation: Division of Medical Oncology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Brian A
authors.initials: BA
authors.lastname: Costello
authors.affiliation: Division of Urology, State University of New York at Stony Brook, Stony Brook, New York.
authors.forename: Anthony T
authors.initials: AT
authors.lastname: Corcoran
authors.affiliation: Division of Medical Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania.
authors.forename: Yu-Ning
authors.initials: YN
authors.lastname: Wong
authors.affiliation: Division of Urologic Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania.
authors.forename: Robert G
authors.initials: RG
authors.lastname: Uzzo
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota.
authors.forename: Bradley C
authors.initials: BC
authors.lastname: Leibovich
authors.affiliation: Division of Urologic Oncology, Fox Chase Cancer Center-Temple University Health System, Philadelphia, Pennsylvania.
authors.forename: Alexander
authors.initials: A
authors.lastname: Kutikov
authors.affiliation: Department of Urology, Mayo Clinic, Rochester, Minnesota. Electronic address: boorjian.stephen@mayo.edu.
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Boorjian
mesh_terms: D002292:Carcinoma, Renal Cell / Q000556:secondary / Q000601:surgery / Q000628:therapy*; D003131:Combined Modality Therapy; D065426:Cytoreduction Surgical Procedures; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007167:Immunotherapy; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D010818:Practice Patterns, Physicians' / Q000639:trends; D012042:Registries; D012189:Retrospective Studies; D013997:Time Factors; D014481:United States
keywords: carcinoma; kidney; neoplasm metastasis; nephrectomy; physician's practice patterns; renal cell