Cytoreductive Nephrectomy Improves Survival in Metastatic Renal Cell Carcinoma Patients With Longer Life Expectancy
Prior to the advent of targeted therapy, cytoreductive nephrectomy was associated with a 6-month improvement in overall survival in metastatic renal cell carcinoma. With the development of new and better targeted therapies for metastatic renal cell carcinoma, the appropriate use of cytoreductive nephrectomy has been questioned. A new study provides some guidance as to which patients with metastatic renal cell carcinoma can expect to have a survival benefit from cytoreductive nephrectomy in the targeted therapy era.
Patients with synchronous metastatic renal cell carcinoma who have a life expectancy of 1 year or more appear to have a survival benefit if treated with targeted therapy and cytoreductive nephrectomy, whereas those with a shorter life expectancy will probably have no benefit, according to the study, which was presented at the 2014 Genitourinary Cancers Symposium in San Francisco (Abstract 396).
“Not all patients with metastatic renal cell carcinoma should undergo cytoreductive nephrectomy. Patients with longer estimated survival may benefit, but those with four or more risk factors [by International Metastatic RCC Consortium Database (IMDC) criteria] and limited life expectancy should not have this surgery. Of course there may be exceptions to this rule, but this is an interesting approach to patient selection,” said Daniel Y. C. Heng, MD, MPH, FRCPC, of Tom Baker Cancer Center, University of Calgary, Canada.
Two prospective phase III clinical trials are currently evaluating cytoreductive nephrectomy—CARMENA and SURTIME—and results of those should be more definitive than this retrospective analysis..
Study Details
The current analysis was based on data from consecutive patients at 20 international cancer centers treated with targeted therapy for metastatic renal cell carcinoma; of the 3,245 total patients, 2,569 were treated with cytoreductive nephrectomy. After excluding patients undergoing cytoreductive nephrectomy before metastasis occurred (about 49%), the final numbers for the analysis were 676 for no nephrectomy and 982 who had cytoreductive nephrectomy.
Patients in the cytoreductive nephrectomy group had better prognostic profiles than did those in the no cytoreductive nephrectomy group, with 9% vs 1%, respectively, having favorable risk, and 63% vs 45% having intermediate risk. “This is not surprising because of patient selection criteria for surgery, so we have to adjust results according to baseline characteristics,” Dr. Heng said.
In a univariate analysis of overall survival, the cytoreductive nephrectomy group lived longer: 20.6 vs 9.5 months (adjusted hazard ratio = 0.60, 95% confidence interval = 0.52–0.69, P < .0001). A multifactorial analysis adjusted for IMDC criteria found an incremental benefit of cytoreductive nephrectomy as survival lengthened, but not much benefit with shorter life expectany.
IMDC criteria build on Memorial Sloan Kettering Cancer Center criteria, and include Karnofsky performance status < 80%, time to interval from diagnosis of < 1 year, and four lab tests for anemia, hypercalcemia, neutrophilia, and thrombocytosis.
There were insufficient numbers of patients to compare cytoreductive nephrectomy vs no cytoreductive nephrectomy in patients who had all six prognostic factors, but a significant survival benefit was detected in those with zero to three prognostic factors, Dr. Heng said.
“If you had one factor, the difference in median [overall survival favoring cytoreductive nephrectomy] was about 8 months; if you had two factors, the difference was 10 months; and if you had three factors, the difference was 6 months,” Dr. Heng said.
For full disclosures of the study authors, view the study abstract at www.gucasym.org.
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