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Rates of cytoreductive nephrectomy appear stable in targeted therapy era
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Thirty-five percent of patients who received targeted therapy for renal cell carcinoma underwent cytoreductive nephrectomy, according to the results of retrospective study.
The addition of cytoreductive nephrectomy to targeted therapy may also confer an OS benefit, results showed.
Toni K. Choueiri
“Historically, management of patients with metastatic renal cell carcinoma included cytoreductive nephrectomy in selected patients in combination with immunotherapy, given the results of two randomized trials demonstrating an OS advantage of 5.8 months in a combined analysis study,” Toni K. Choueiri, MD, medical oncologist and director of the Kidney Cancer Center and clinical director of Lank Center for Genitourinary Oncology at Dana-Farber/Brigham and Women’s Cancer Center, and colleagues wrote. “The significant advent of targeted therapies has blurred the role of cytoreductive nephrectomy in contemporary patients diagnosed with metastatic renal cell carcinoma.”
Although guidelines support the role of cytoreductive nephrectomy, studies have suggested its use is declining. This trend may be due to a lack of data evaluating the use of cytoreductive nephrectomy in combination with targeted therapies.
Choueiri and colleagues used the National Cancer Data Base to evaluate the rate of cytoreductive nephrectomy use — and whether it confers an OS benefit — in 15,390 patients (median age at diagnosis, 63 years; interquartile range, 55-71) with metastatic renal cell carcinoma treated with targeted therapies from 2006 to 2013. The majority of patients were men (68.6%), white (80.1%) and had government insurance (50.4%).
Thirty-five percent (n = 5,374; median age at diagnosis, 60 years) of patients underwent cytoreductive nephrectomy. The use of cytoreductive nephrectomy appeared stable between 2006 and 2013 (range, 32%-34%; annual percentage change, 1.01%; 95% CI, –1.64 to 3.73).
“Although our report suggests on overall stabilization of cytoreductive nephrectomy use with targeted therapy in recent years, the overall rate of cytoreductive nephrectomy observed in the current study was lower than the overall rate of cytoreductive nephrectomy observed in data originating from centers of excellence (approximately 58% to 85%),” Choueiri and colleagues wrote.
In a multivariate analysis, age, insurance and place of treatment appeared linked to cytoreductive nephrectomy use.
Compared with younger patients, cytoreductive nephrectomy was less common among patients aged 60 to 69 years (OR = 0.68; 95% CI, 0.6-0.77), 70 to 79 years (OR = 0.68; 95% CI, 0.39-0.52), and 80 years or older (OR = 0.18; 95% CI, 0.14-0.22).
Cytoreductive nephrectomy was less common among patients treated at a community center (OR = 0.61; 95% CI, 0.52-0.72), comprehensive community center (OR = 0.72; 95% CI, 0.64-0.8) or integrated network program (OR = 0.79; 95% CI, 0.64-0.97) compared with those treated at an academic center.
Further, compared with those insured by Medicare or Medicaid, uninsured patients were less likely to undergo cytoreductive nephrectomy (OR = 0.76; 95% CI, 0.63-0.92). Privately insured patients were more likely to undergo the procedure (OR = 1.27; 95% CI, 1.17-1.38).
Black patients appeared less likely to undergo cytoreductive nephrectomy (OR = 0.64; 95% CI, 0.79-1.09) than white patients.
Researchers evaluated survival outcomes in 12,995 patients (cytoreductive nephrectomy, n = 4,559), 10,882 of whom died.
Median OS appeared longer among patients who underwent cytoreductive nephrectomy (17.1 months; 95% CI, 16.3-18) than for those who did not (7.7 months; 95% CI, 7.4-7.9). In a propensity-score adjusted sensitivity analysis, cytoreductive nephrectomy decreased risk for all-cause mortality (HR = 0.45; 95% CI, 0.4-0.5).
Results of an incremental benefit analysis showed the benefit of cytoreductive nephrectomy increased as patients lived longer. The benefit was 0.7 months in patients who survived for 6 months or less and 3.6 months for patients who survived for 24 months or less.
Researchers acknowledged the retrospective nature of the study, the inability to examine cause-specific mortality and PFS, and a lack of treatment-specific data may be limitations to these findings.
“This study is the largest sample size to date showing that cytoreductive nephrectomy has an OS benefit in patients treated with targeted therapy, while adjusting for other factors,” the researchers wrote. “However, careful patient selection remains critical in determining if patients will benefit from cytoreductive nephrectomy.” – by Nick Andrews
Disclos ure: Please see the full study for a list of all researchers' relevant financial disclosures.
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