San Diego, CA USA (UroToday.com) In this session, Dr. Miller spoke to us about optimization of surveillance following nephrectomy for renal cell carcinoma (RCC). The 2016 AUA and NCCN guidelines currently stratify patients by stage with low risk patients recommended to receive imaging for 3 years’ duration and higher risk patients getting 5 years of postoperative imaging. After these time points, further screening is up to the discretion of the ordering physician.
Despite these guidelines, the effectiveness of capturing RCC recurrence is unclear with up to 1/3 of all recurrences missed when AUA/NCCN guidelines were used. Further the AUA and NCCN follow-up guidelines fail to account for change in recurrence risk over time, influence of competing risks to mortality, RCC recurrences that occur after 5 years, and the economic burden of follow-up imaging on the health care system which has been estimated to approach $13,000 per patient.
Some barriers to surveillance optimization include an uncertain impact of postoperative imaging on survival and influences of lead-time bias. Even still, surveillance continues to be fundamental to RCC care due to its perceived benefits. Proponents argue the utility of postoperative imaging may include detection of post op complications (e.g. renal failure), the ability to capture recurrences early leading to more options for therapy, and advancements in targeted therapy generating favorable impacts on survival.
Dr. Miller then argued for a restructuring of RCC surveillance. A sophisticated surveillance algorithm ought to move beyond TNM staging and include more features leading to more individualized strategies. She did warn, however, that if surveillance models become overly complicated and burdensome, underutilization and heterogeneous care will be perpetuated.
The current framework for postoperative imaging uses linear calculation. Instead of a simply stage-based risk stratification scheme, Dr. Miller argued for a transition time point away from rigorous identification of recurrent disease at the point where competing health risks exceed the risk of RCC recurrence. She proposed Weibull modeling which captures the dynamic interaction between risk of RCC recurrence and risk of non-RCC death, thereby identifying key transition time points.
Lastly, these models require external validation to verify their effectiveness as well as outcome assessment (including patient reported outcomes) to compare new algorithms to current frameworks
Dr. Miller closed by noting that the current surveillance framework merits optimization, which can be done by restructuring surveillance and developing more sophisticated algorithms.
Presented By: Suzanne B. Miller, MD