Less Aggressive Surgery Linked to Improved Survival in Older Patients With Kidney Cancer

Partial nephrectomy is associated with better overall survival than radical nephrectomy in older patients with early-stage kidney cancer, according to the results of a recent study that examined long-term survival in patients eligible for either of the two treatment options.

“Our findings suggest that by judiciously expanding the use of partial nephrectomy, clinicians can optimize survival outcomes among patients seeking treatment for early-stage kidney cancer,” Hung-Jui Tan, MD, a urology resident at the University of Michigan Medical School in Ann Arbor, and colleagues wrote.

For their study, the investigators reviewed data in 7138 Medicare recipients with stage T1a renal cancer who were treated with partial or radical nephrectomy from 1992 through 2007.

Although partial nephrectomy is widely accepted as the preferred treatment for patients with small, early-stage kidney cancer, recent clinical trial data showing improved survival with radical nephrectomy have called into question this notion, the researchers noted. However, the data supporting more aggressive surgery are drawn from a European Organization for Research and Treatment of Cancer study that had several major drawbacks. For example, the study was conducted at a time when surgeons rarely performed partial nephrectomy, which may limit its application to contemporary clinical practice. The study was also limited by accrual problems and premature closure.

The present analysis included 1925 patients treated with partial nephrectomy and 5213 patients treated with radical nephrectomy. The data source was the National Cancer Institute’s SEER database.

During a median follow-up of 62 months, 487 (25.3%) and 2164 (41.5%) patients died following partial or radical nephrectomy, respectively.

Kidney cancer was identified as the cause of death in 37 patients (1.9%) treated with partial nephrectomy and 222 patients (4.3%) treated with radical nephrectomy.

Patients treated with partial nephrectomy had a significantly lower risk of death (hazard ratio [HR] = 0.54; 95% CI, 0.34-0.85). The predicted survival improvement in this cohort was 5.6 (95% CI, 1.9-9.3), 11.8 (95% CI, 3.9-19.7), and 15.5 (95% CI, 5.0-26.0) percentage points at 2, 5, and 8 years after surgery (P <.001).

There was no dif ference in kidney cancer-specific survival between treatment groups (HR = 0.82; 95% CI, 0.19-3.49).

Tan et al said that while patients treated with partial nephrectomy live longer than those treated with radical nephrectomy, partial nephrectomy is “a technically challenging operation” that may produce significant complications like hemorrhage and urinary fistula, which are less likely to occur in patients treated with radical nephrectomy. Accordingly, when deciding on a treatment strategy, clinicians need to consider both the benefits of treatment and the risk of acute surgical morbidity, as well as the possibility of alternative treatment options, including active surveillance and ablative therapies, the researchers noted.

Tan H-J, Norton EC, Ye Z, et al. Long-term survival following partial vs radical nephrectomy among older patients with early-stage kidney cancer. JAMA. 2012;307(15):1629-1635.