An accurate assessment of a patient’s kidney function is critical for determining eligibility for anticancer treatments. In a paper published by Casal et al in The Lancet Oncology, researchers found that removing race-based adjustments from equations estimating kidney function may negatively impact care for Black patients with cancer.
The analysis showed that removal of race from these calculations—as proposed by prominent health organizations—would make many Black people ineligible for cancer treatments and may prompt oncologists to give Black patients a lower dose of anticancer medications than clinically needed.
Black patients in the United States are more frequently diagnosed with cancer and are more likely to die from it than White Americans. The researchers argue that because Black Americans are already more likely to be undertreated, an optimal dose of anticancer drugs is vital to their treatment—and that, until practical alternatives become available, race remains a factor that should not be ignored in considerations of dosages for cancer treatments.
“Ultimately, we hope our results raise awareness of the issue, and we urge doctors to use appropriate clinical judgement and to think logically about weighing the risks and benefits of cancer drugs in the context of the patient’s kidney function,” said co-senior author Thomas Nolin, PharmD, PhD, Associate Professor of Pharmacy and Therapeutics at the University of Pittsburgh School of Pharmacy.
eGFR Estimates
To quickly assess kidney function in a way that doesn’t require invasive procedures, clinicians use a mathematical equation that correlates the creatinine concentration in the blood with the rate of creatinine excretion by the kidneys, resulting in a parameter called estimated glomerular filtration rate, or eGFR. The equations used to calculate eGFR may be used to estimate kidney function in patients with cancer and dictate their eligibility for anticancer drugs.
One equation commonly used to calculate eGFR—known as the CKD-EPI equation—includes adjustments for the patient’s age and sex. In addition, the CKD-EPI equation includes a factor to adjust for race that multiplies the kidney function estimate by 1.16 if a patient self-identifies as Black.
Recently, a joint task force established by the National Kidney Foundation (NKF) and the American Society of Nephrology (ASN) proposed replacing eGFR equations that include race with alternative equations that do not to prevent propagating the misconception of race as a biologic determinant of health and disease.
The authors of The Lancet Oncology paper said that while it is unclear why a person’s race is associated with a different relationship between the blood creatinine level and kidney function, the existence of such a relationship has been suggested based on data from thousands of patients, and that the nature of the relationship merits examination.
Study Findings
To determine whether taking race into account in kidney function calculations might benefit or harm Black patients with cancer, the researchers combed through 15 years of data collected as part of early clinical trials conducted by the National Cancer Institute.
The analysis showed that Black patients would be deemed ineligible to receive anticancer drugs or recommended to get lower doses more frequently if the race term wasn’t included. The number of patients ineligible for therapy or recommended to receive any renal dose adjustment when CKD-EPI without race vs CKD-EPI was used increased by 72% (from 25 of 340 to 43 of 340 patients) for cisplatin, by 120% (from 5 to 11) for pemetrexed, by 67% (from 3 to 5) for bendamustine, by 150% (from 10 to 25) for capecitabine, by 150% (from 10 to 25) for etoposide, by 67% (from 3 to 5) for topotecan, by 61% (from 74 to 119) for fludarabine, and by 163% (from 8 to 21) for bleomycin. Up to 18% of patients had discordant recommendations using CKD-EPI without race vs CKD-EPI.
“Currently, the NKF-ASN task force is exploring alternative methods of assessing kidney function that do not include race, and the current clinical treatment paradigm leading to disparate outcomes in Black patients should be investigated,” said Dr. Nolin.
Disclosure: This research was supported in part by the National Institutes of Health. For full disclosures of the study authors, visit thelancet.com.
