title: The effect of delaying nephrectomy on oncologic outcomes in patients with renal tumors greater than 4cm.
abstract: OBJECTIVE
  Delaying nephrectomy<3 months does not adversely affect treatment outcome of renal tumors. Whether surgical waiting time (SWT; time from diagnosis to surgery)>3 months affects treatment outcome for large renal masses has not been well studied. We aimed to evaluate if SWT is associated with treatment outcome of renal masses >4cm and identify patients who are more likely to experience prolonged SWT.
  
  
  METHODS
  Data from 1,484 patients undergoing radical or partial nephrectomy at a single institution for a nonmetastatic renal mass>4cm between 1995 and 2013 were reviewed. Patients with benign tumors and incomplete preoperative data were excluded. The association between SWT and disease upstaging at the time of surgery and recurrence at 2 and 5 years was assessed using logistic regression. Cancer-specific survival (CSS) and overall survival were assessed with landmark survival analyses and multivariable Cox proportional hazards models. All analyses were adjusted for patient and tumor characteristics.
  
  
  RESULTS
  Of the final cohort of 1,278 patients, 267 (21%) had SWT>3 months. Patients with larger, symptomatic tumors had shorter SWT. Median follow-up for survivors was 3.8 years (interquartile range: 1.5-7.4). On multivariable analysis, SWT was not associated with disease upstaging, recurrence, or CSS. Longer SWT was associated with decreased overall survival (hazard ratio = 1.17; 95% CI: 1.08-1.27; P = 0.0002). Sex and tumor size, histology, and presentation were associated with disease upstaging, recurrence, and CSS. The most common cause for surgical delay>3 months was evaluation and treatment of comorbidities.
  
  
  CONCLUSIONS
  Patient and tumor characteristics, rather than SWT, were associated with disease upstaging, recurrence, and CSS, and should guide the decision to delay surgery when treating nonmetastatic renal tumors>4cm.
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY. Electronic address: roymano78@gmail.com.
authors.forename: Roy
authors.initials: R
authors.lastname: Mano
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Emily A
authors.initials: EA
authors.lastname: Vertosick
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Abraham Ari
authors.initials: AA
authors.lastname: Hakimi
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Itay A
authors.initials: IA
authors.lastname: Sternberg
authors.affiliation: Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Daniel D
authors.initials: DD
authors.lastname: Sjoberg
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Melanie
authors.initials: M
authors.lastname: Bernstein
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Guido
authors.initials: G
authors.lastname: Dalbagni
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Jonathan A
authors.initials: JA
authors.lastname: Coleman
authors.affiliation: Department of Surgery, Urology Service, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Paul
authors.initials: P
authors.lastname: Russo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D053208:Kaplan-Meier Estimate; D007668:Kidney / Q000473:pathology / Q000601:surgery*; D007680:Kidney Neoplasms / Q000473:pathology; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009392:Nephrectomy / Q000379:methods*; D017063:Outcome Assessment, Health Care / Q000379:methods / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D061665:Time-to-Treatment; D047368:Tumor Burden; D014850:Waiting Lists
keywords: Nephrectomy; Outcome prediction; Renal cell carcinoma; Surgical treatment delay