Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-Based Approach.
OBJECTIVE
The appropriate duration of surveillance for renal cell carcinoma (RCC) after radical or partial nephrectomy remains unknown, and evidence to support current guidelines are lacking. Herein, we provide an approach to surveillance that balances the risk of recurrence versus the risk of non-RCC death.


METHODS
We identified 2,511 patients who underwent surgery for M0 RCC between 1990 and 2008. Patients were stratified for analysis by pathologic stage (pT1Nx-0, pT2Nx-0, pT3/4Nx-0, and pTanyN1), relapse location (abdomen, chest, bone, and other), age (< 50, 50 to 59, 60 to 69, 70-79 and ≥ 80 years), and Charlson comorbidity index (CCI; ≤ 1 and ≥ 2). Risks of disease recurrence and non-RCC death were estimated by using parametric models for time-to-failure with Weibull distributions. Surveillance duration was estimated at the point when the risk of non-RCC death exceeded the risk of recurrence.


RESULTS
At a median follow-up of 9.0 years (interquartile range, 6.4 to 12.7 years), a total of 676 patients developed recurrence. By using a competing-risk model, vastly different surveillance durations were appreciated. Specifically, among patients with pT1Nx-0 disease and a CCI ≤ 1, risk of non-RCC death exceeded that of abdominal recurrence risk at 6 months in patients age 80 years and older but failed to do so for greater than 20 years in patients younger than age 50 years. For patients with pT1Nx-0 disease but a CCI ≥ 2, the risk of non-RCC death exceeded that of abdominal recurrence risk already at 30 days after surgery, regardless of patient age.


CONCLUSIONS
We present an individualized approach to RCC surveillance that bases the duration of follow-up on the interplay between competing risk factors of recurrence and non-RCC death. This strategy may improve the balance between the derived benefit from surveillance and medical resource allocation.
All authors: Mayo Clinic, Rochester, MN.
Suzanne B
SB
Stewart-Merrill
All authors: Mayo Clinic, Rochester, MN.
R Houston
RH
Thompson
All authors: Mayo Clinic, Rochester, MN.
Stephen A
SA
Boorjian
All authors: Mayo Clinic, Rochester, MN.
Sarah P
SP
Psutka
All authors: Mayo Clinic, Rochester, MN.
Christine M
CM
Lohse
All authors: Mayo Clinic, Rochester, MN.
John C
JC
Cheville
All authors: Mayo Clinic, Rochester, MN.
Bradley C
BC
Leibovich
All authors: Mayo Clinic, Rochester, MN. frank.igor@mayo.edu.
Igor
I
Frank
D000368:Aged; D000369:Aged, 80 and over; D002292:Carcinoma, Renal Cell / Q000453:epidemiology* / Q000556:secondary / Q000601:surgery*; D015897:Comorbidity; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007680:Kidney Neoplasms / Q000453:epidemiology* / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000453:epidemiology*; D009367:Neoplasm Staging; D009392:Nephrectomy / Q000379:methods; D011159:Population Surveillance / Q000379:methods*; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D014481:United States / Q000453:epidemiology