Abstract
Purpose
Cytoreductive nephrectomy (CN) benefits a subset of patients with metastatic renal cell carcinoma (mRCC), however proper patient selection remains complex and controversial. We aim to characterize urologists’ reasons for not undertaking a CN at a quaternary cancer center.
Methods
Consecutive patients with mRCC referred to MSKCC urologists for consideration of CN between 2009 and 2019 were included. Baseline clinicopathologic characteristics were used to compare patients selected or rejected for CN. The reasons cited for not operating and the alternative management strategies recommended were extrapolated. Using an iterative thematic analysis, a framework of reasons for rejecting CN was designed. Kaplan–Meier estimates tested for associations between the reasons for not undertaking a CN and overall survival (OS).
Results
Of 297 patients with biopsy-proven mRCC, 217 (73%) underwent CN and 80 (27%) did not. Median follow-up of patients alive at data cut-off was 27.3 months. Non-operative patients were older (p = 0.014), had more sites of metastases (p = 0.008), harbored non-clear cell histology (p = 0.014) and reduced performance status (p < 0.001). The framework comprised seven distinct themes for recommending non-operative management: two patient-fitness considerations and five oncological considerations. These considerations were associated with OS; four of the oncological factors conferred a median OS of less than 12 months (p < 0.001).
Conclusion
We developed a framework of criteria by which patients were deemed unsuitable candidates for CN. These new insights provide a novel perspective on surgical selection, could potentially be applicable to other malignancies and possibly have prognostic implications.
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Code availability
Statistical analyses were completed using R version 3.5.1 (R Core Development Team, Vienna, Austria). Code can be provided upon request.
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Funding
Supported by: the Sidney Kimmel Center for Prostate and Urologic Cancers and the National Institutes of Health/National Cancer Institute to Memorial Sloan Kettering Cancer Center through the Cancer Center Support Grant, award number P30 CA008748.
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AWS: Data collection, data analysis, manuscript writing/editing. KA: Data collection, manuscript writing. RGD: Project development, manuscript writing, data analysis. KW: Project development, data collection. SW: Manuscript writing. RM: Project development, manuscript editing. SI: Data collection. JM: Project development, data collection. ER: Project development, data analysis. RRK: Project development, manuscript editing. RJM: Project development, manuscript editing. MHV: Project development, manuscript editing. JAC: Project development, data collection, manuscript editing. AAH: Project development, data collection, manuscript editing. PR: Project development, data collection, manuscript editing.
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Silagy, A.W., Attalla, K., Dinatale, R.G. et al. A qualitative framework of non-selection factors for cytoreductive nephrectomy. World J Urol 39, 3359–3365 (2021). https://doi.org/10.1007/s00345-021-03650-4
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DOI: https://doi.org/10.1007/s00345-021-03650-4