Use of Nephron-Sparing Surgery for Stage I RCC Increasing

The use of nephron-sparing surgery (NSS) to treat stage I renal tumors in Australia increased between 2009 to 2013, showing increased compliance with international guidelines, according to the results of a study published in BJU International. However, the study also showed that adoption of the use of NSS to treat larger T1b tumors had been slower.

“Our study has shown that the treatment of small renal tumors in Australia has undergone a substantial change in a relatively short period, with NSS now the standard of care for T1a tumors,” wrote researcher Vicki White, of the Cancer Council Victoria and the University of Melbourne, Australia, and colleagues. “Our data suggest that while treatment of small renal tumors is increasingly in line with international standard, this is not the case for the treatment of large T1 tumors. The slow adoption of NSS in the treatment of T1b tumors warrants further investigation to identify barriers to its use.”

After increasing evidence established that similar outcomes were achieved for small renal tumors with the use of NSS and radical nephrectomy, treatment guidelines for the management of these tumors were updated to recommend use of NSS as a preferred standard of care for tumors less than 4 cm.

With this study, White and colleagues analyzed treatment patterns in Australia to determine whether the use of NSS changed from 2009 to 2013. The study included all adult cases of renal cell carcinoma (RCC) diagnosed in Australia in 2009, 2012, and 2013 (n = 1,836). Medical record reviews were conducted to obtain tumor and treatment data for each patient.

Of the identified patients with RCC from the registry, 64% of tumors were stage I in 2009; 66% in 2012; and 69% in 2013.

For T1a tumors, there was a significant increase in the use of NSS for patients in both metropolitan and non-metropolitan areas. In metropolitan areas, the rate of NSS was 43% in 2009, 58% in 2012, and 69% in 2013 (P < .05). For non-metropolitan areas, the rate of NSS was 27% in 2009, 49% in 2012, and 61% in 2013 (P < .01).

“Encouragingly, the increase in use of NSS for T1a tumors was seen in all demographic groups, in both public and private hospital systems and in both low- and high-volume hospitals, suggesting that all patients were benefiting from these clinical practice changes,” the researchers wrote.

A multivariable analysis showed that patients with T1a tumors in 2012 were twice as likely (odds ratio, 2.00; 95% CI, 1.34–2.97) and in 2013 were three times as likely (odds ratio, 3.15; 95% CI, 2.13–4.68) to be treated with NSS than patients in 2009.

There was also a significant increase in the use of NSS for patients with T1b tumors from 8% in 2009 to 20% in 2013 (P < .05).

“Despite guidelines suggesting that NSS should be considered when treating T1b tumors, our study found that of the patients having surgery, the vast majority were treated by radical nephrectomy in 2013,” the researchers wrote.