Enhancing Patient-Centered Communication in Small Renal Mass Management - Kathryn Hacker Gessner

June 2, 2023

Kathryn Gessner discusses her focus on improving patient-centered communication for managing small renal masses, an issue faced by 30% of such patients. She explores how multiple management options, from surgical resection to active surveillance and cryoablation, can lead to decisional conflict for patients. Her work reveals that 20-30% of these masses are benign and carry a low risk of mortality and metastasis. Gessner and her team are developing the Grade SRM clinical trial to study decisional conflict and enhance patient-centered communication. Their preliminary results indicate a need for individualized counseling based on factors such as education levels, prior surgery experience, and the nature of the renal mass. Future efforts include collaborations with the UNC School of Media and Journalism to further improve patient communication.


Kathryn Hacker Gessner, MD, PhD, Urologic Oncology Fellow, University of North Carolina School of Medicine, Chapel Hill, NC

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

Read the Full Video Transcript

Ruchika Talwar: Hi, my name's Ruchika Talwar, and during this year's 2023, AUA annual meeting, I've been covering health policy content. I'm now joined by Dr. Kathryn Gessner, who's a urologic oncology fellow at UNC. We'll be discussing her work in patient-centered communication for the management of small renal masses. Dr. Gessner, thanks for being with us today.

Kathryn Gessner: Thanks for having me.

Ruchika Talwar: So tell me a little bit of background on the work that you're presenting at this meeting.

Kathryn Gessner: Absolutely. So we know from previous studies that 30% of patients with small renal masses, which are defined as masses in their kidney less than four centimeters, experience decisional conflict. Historically, the standard of care for managing small renal masses with surgical resection. However, over the past couple of decades, additional management options, including active surveillance and cryoablation have become more mainstream for management of those masses. And so as patients have more options for management, their conflict regarding which option is best for them increases. And so we're really interested in evaluating the factors that impact patient-centered communication for patients that have small renal masses.

Ruchika Talwar: Yeah. And this is really interesting work, and I'm intrigued because as years have gone on, we've been doing imaging for all sorts of other things, and we've been catching these often, honestly, clinically insignificant, small renal masses earlier. And that leads us to have important conversations with patients. And I think a cancer diagnosis is a big deal. They don't hear small renal mass, they don't hear lesion, they just hear the C word.

Kathryn Gessner: Right. Yeah. Absolutely. We know that 20% to 30% of these masses are actually benign. And so as urologists, we understand that. When they hear from an ED provider or their primary care doctor that they have a mass on their kidney, frequently that C word is used. Even in the setting of cancer. We know that masses less than four centimeters have a low risk of mortality and low likelihood of metastasis. And so as urologists, it's very, very simple for us to say, "Well, let's just watch it." But for patients that can be really anxiety provoking and creates a lot of conflict for them.

Ruchika Talwar: Yeah. Yeah. So let's get into the details of your investigation.

Kathryn Gessner: Absolutely. As part of an evaluation of decisional conflict and how we can improve communication and risk stratifications of small renal masses, we developed when I was a resident at UNC, actually, a clinical trial called Grade SRM. And this is a hybrid, non-randomized comparative clinical trial with two main outcomes. So first, we're interested in evaluating genomic biomarkers and looking at whether we can utilize standard of care renal mass biopsies, and surgical specimens to look at the concordance of genomic biomarkers across them.

So really getting at the question of can we biopsy a small renal mass and use the genomics from that to predict what the rest of the tumor looks like? So that's one outcome. The other outcome is looking at decisional conflict and really looking at decision making factors, patient-centered communication, and how we can improve that in patients with small renal masses. And so patients, as part of the study, we enrolled 265 patients. They underwent standard of care counseling for their small renal masses and then elected to either undergo a renal mass biopsy or not. And then after standard of care counseling performed a whole barrage of surveys, looking at patient reported outcomes, decision making characteristics, and then after they selected which treatment to undergo, they also repeated those surveys. And then over a subsequent follow up, we'll have kind of decisional conflict, patient-centered communication, anxiety, and also ultimately looking at regret with their treatment's selection.

Ruchika Talwar: Interesting. I love how you folded this important question into a trial that you were doing for other reasons. So it's great because it's work that we need to really pay attention to. So standard of care counseling, tell me what does that entail?

Kathryn Gessner: Absolutely. So patients come into our clinic with a newly diagnosed small renal mass. As you alluded to already usually just seen incidentally on imaging that was obtained for other reasons. And we discuss the options with them. So we utilize shared decision making and talk about active surveillance, talk about the role of renal mass biopsy, talk about partial versus radical nephrectomy and also cryoablation. And so that counseling really discusses all of those options. And then based off of their characteristics, so their health status, surgical history, the size of the mass, the location of the mass, how complex it is, the likelihood that we could do a partial nephrectomy versus radical, all of those factors get rolled into that discussion to really determine for that patient, which is the best option.

Ruchika Talwar: Yeah. Yeah. So tell me about your results.

Kathryn Gessner: For this study, we looked at factors associated with poor patient-centered communication. So really what patient characteristics, tumor characteristics, and decision making characteristics of the patient or decision behavior really impact how they view or how they perceive communication from their physicians. And so we utilized an instrument, a validated instrument, looking at how patients perceive in information and communication.

Ruchika Talwar: That's interesting. I'll pause for a second just to make a comment. I think that as physicians, we are a little bit set in our ways. Once we find a counseling technique we like, we tend to stick with that. And I love that you're trying to tie in how patients perceive that with certain characteristics because one size does not fit all, but it's hard for us to adapt, I'd say. So I'll let you continue.

Kathryn Gessner: Yeah. No, I think that is the crux of this. As physicians, we sometimes create a spiel or a speech for each kind of ailment that we treat. And our results really suggest that we need to individualize our counseling for each patient. And so we found that patients perceive worse communication when they have lower levels of education, interestingly, when they have not had surgery before. So that kind of plays into how patients experiences, prior experiences impact how they perceive communication from their surgeon.

We found that patients that have cystic masses or mixed masses also perceive worse communication. And that really gets at, I think, the fact that those are a lot harder to talk to patients about when a patient has a solid mass, it's very easy to describe that. But when we're talking about the Bosniak system and classification system and the risk of malignancy in those cystic masses, it's a lot harder for us as urologists to describe that.
Interestingly, we found that if patients saw a urologist prior to coming to UNC, they perceived worse communication. And so I think that gets at mixed messages and they're probably hearing one thing from the outside urologist, and then perhaps a different message or different management options from the UNC urologist.

Ruchika Talwar: Interesting.

Kathryn Gessner: And it's very interesting because I have always said patients should get second opinions, like that standard, they should hear different options and different ways that urologists perceive things. And that kind of our results show that can create worse communication in a way.

Ruchika Talwar: Yeah. So, what can we do as a urology community to adapt our techniques in the space of patient counseling to make sure that our patients perceive better communication?

Kathryn Gessner: Yeah. I think it gets at patient needs. We need to identify how our patients perceive communication and what they need from us. So if a patient hasn't had surgery before, perhaps we need to go into more detail about that. If they have a cystic mass, we need to make sure that they understand the implication of that and that we typically don't biopsy those. We also found that lower information seeking behavior in patients resulted in worse perceived communication scores. And so providing patients that aren't going to seek information on their own with information could help that. And so we're really looking at how we can improve patient communication. We're working with our school of media and journalism and experts there. It's amazing. We have these experts in communication at UNC, and we're partnering with them to look at how we can really improve communication with patients about small renal masses.

And then we have a mixed method study that's funded by the DOD that is looking at decision making process and patient communication. And so we're doing a qualitative, or we've recently completed about 40 qualitative interviews. And preliminarily, we're seeing kind of high level themes come out in our preliminary analysis that shows that patients perceive better communication when they find their surgeons are confident, when the patients perceive them as knowledgeable, and when the patients perceive them as trustworthy. And so really kind of exuding those characteristics may also improve communication, which I think is interesting.

Ruchika Talwar: Yeah. This is fascinating work. So I'm really excited to see what next you bring out from all of these investigations, especially these collaborations with the School of Communication because I think that we do have all these resources and experts that we can partner with at academic institutions, but I haven't heard of anyone having that idea before. So we'll stay tuned for that work.

Kathryn Gessner: Thanks. Yeah, we're really excited to see where it goes.

Ruchika Talwar: Awesome. Well, congratulations on the study that you're presenting at this meeting. I think that it's really going to help improve the quality of patient counseling that we give in this often difficult space of small renal masses.

Kathryn Gessner: Thank you. Thanks for having me.