Functional Status Affected Kidney Cancer Care, Survival

Patients with kidney cancer who are considered to be in poor functional health were less likely to receive cancer-directed surgery to treat their disease and were at a greater risk from death from something other than kidney cancer, according to the results of a study published in Cancer.

Although surgery is the standard first-line treatment for patients with kidney cancer, its use is carefully considered in patients with underlying health conditions, especially in older patients.

“The results of the current study also suggest that patient function has begun to seep into the collective decision-making process for patients with kidney cancer,” wrote researchers led by Hung-Jui Tan, MD, of the University of North Carolina at Chapel Hill. “Across the spectrum of disease, patients in poor functional health were found to receive treatment less often than those with no or limited evidence of functional decline.”

Tan and colleagues compared kidney cancer mortality, other-cause mortality, and receipt of cancer-directed surgery according to functional health status in a group of 28,326 elderly patients with primary kidney cancer taken from Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 2000 to 2009. They hypothesized that there would be a higher incidence of non–kidney cancer mortality and less surgery among adults with evidence of functional decline or disability.

They examined Medicare claims for indicators of reduced functional status such as the use of mobility-assist devices, falls, fractures, home oxygen, pressure ulcers, or evidence of overall dysfunction or disability. They identified 13,619 (48.1%) adults with at least one function-related indicator. Higher indicator status was significantly associated with older age, greater comorbidity, female sex, being unmarried, lower socioeconomic status, and higher stage of disease.

In an analysis adjusting for patient characteristics, the researchers found that those patients with at least one function-related indicator (hazard ratio [HR], 1.10 [95% CI, 1.04–1.16]) and those with two or more (HR, 1.46 [95% CI, 1.39–1.53]) had a higher risk of other-cause mortality compared with patients without any function-related indicators.

Results also showed that patients with two or more function-related indicators were significantly less likely to undergo surgery (odds ratio, 0.61 [95% CI, 0.56–0.66]). However, the researchers noted that there was no difference for use of surgery for patients with zero or one function-related indicator.

This is an indication that disease stage is more often the driver of surgery use, the researchers wrote.

“In the case of patients with stage I kidney cancer, > 75% of patients in poor functional health received cancer-directed surgery despite a 6-fold higher risk of death from causes other than kidney cancer,” the researchers wrote. “Conversely, relatively few patients, including those without a single indicator of disability, are reported to undergo cytoreductive nephrectomy, despite evidence demonstrating a clinical benefit and acceptable tolerability. Therefore, although receipt of surgery does seem to vary with patient function, there appear to be areas of both overtreatment and undertreatment in kidney cancer care.”

“Greater consideration of functionality during decision making may serve as an avenue for improvement in the quality of care delivery for patients with kidney cancer,” the researchers concluded.