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Surveillance Guidelines Miss 30% of Renal Cell Carcinoma Recurrences After Nephrectomy

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Key Points

  • Current surveillance recommendations miss 30% or more of recurrences.
  • Capture of 95% of recurrences would require surveillance for up to 21 years.

In a study reported in the Journal of Clinical Oncology, Stewart et al found that 30% or more of renal cell carcinoma recurrences were missed using National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) guidelines for surveillance after surgery for renal cell carcinoma.

The study involved data from 3,651 patients in the Mayo Clinic prospective database who underwent surgery for M0 renal cell carcinoma between 1970 and 2008. Patients were stratified as AUA low risk (pT1, Nx-0) after partial or radical nephrectomy or as moderate/high risk (pT2-4, Nx-0/pTany, N1).

Recurrence Capture

At median follow-up of 9.0 years (interquartile range = 5.7–14.4 years), 1,088 patients (29.8%) had recurrence. Sites of recurrence were the abdomen in 437 (40.2%), chest in 442 (40.6%), bone in 166 (15.3%), and other in 158 (14.5%). Of all recurrences, 390 (35.9%) would have been detected using 2013 NCCN recommendations, 742 (68.2%) using 2014 NCCN recommendations, and 728 (66.9%) using AUA recommendations. The guidelines were least likely to capture abdominal recurrence, with 19.2%, 59%, and 58.6% detected by 2013 NCCN, 2014 NCCN, and AUA guidelines, respectively.

Time and Cost for Improvement

It was calculated that to capture 95% of recurrences, surveillance would be required for 15 years for partial nephrectomy, 21 years for radical nephrectomy, and 14 years for moderate/high-risk patients. Medicare surveillance costs for one partial nephrectomy patient were $1,228.79 on 2013 NCCN, $2,131.52 on 2014 NCCN, and $1,738.31 on AUA surveillance recommendations. To capture 95% of recurrences, surveillance costs per patient would be $9,856.82 for partial nephrectomy patients, $13,097.26 for radical nephrectomy patients, and $11,189.99 for moderate/high-risk patients.

The investigators concluded: “If strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of renal cell carcinoma recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.”

Bradley C. Leibovich, MD, of the Mayo Clinic, is the corresponding author for the Journal of Clinical Oncology article.

The study was supported by a grant from the National Center for Advancing Translational Sciences, National Institutes of Health. The study authors reported no potential conflicts of interest.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.


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