EAU 2018: Impact Of Hospital Nephrectomy Volume On Intermediate To Long-term Survival In Renal Cell Carcinoma

Copenhagen, Denmark (UroToday.com) With greater focus on improving clinical outcomes, many recent studies have demonstrated superior cancer outcomes with higher clinical volume. Hence, centers of excellence for individual disease processes have begun to arise, allowing centralization of healthcare.

Along the same lines, in this study from the UK, the authors assess the impact of hospital nephrectomy volume on intermediate to long-term survival in patients with renal cell carcinoma (RCC). Prior studies have focused on impact on short-term 30-day outcomes, but their particular focus is longer term clinical outcomes.

They identified 12,912 patients RCC patients treated with radical or partial nephrectomy between 2000 and 2010 from the English Hospital Episode Statistics and National Cancer Data Repository. Survival time was calculated from date of surgery until date of death from any cause or until end of 2015. Median follow-up was 8.1 years.

They defined hospital volume according to the annual number of nephrectomies completed in each hospital per year: <20, 20-39 and ≥40. They specifically assessed 1-year survival conditional to 30-day survival, 3-year survival conditional to 1-year survival, and 5-year survival conditional to 3-year survival.

They had 4,468 patients, 5,309 patients, and 3,135 patients treated at low-volume, medium-volume and high-volume centers, respectively. Interestingly, patients treated at high-volume centers were more likely to be white/Caucasian, receive a minimally invasive approach, but less like to undergo radical nephrectomy and had lower 1-year, 3-year and 5-year mortality.

They found that patients treated in the highest volume category hospitals (≥40 per year) had higher 1-year survival compared with those treated in the lowest volume category (HR 0.72, 95% CI 0.58-0.90, p<0.01). Interestingly, no significant association between hospital volume and survival was observed beyond the first year.

In subgroup analyses based on clinical stage, T1 and T2 patients treated in hospitals performing ≥40 nephrectomies per annum had higher 1-year survival (T1: HR 0.59, 95% CI 0.35-0.98, p=0.04; T2: HR 0.47, 95% CI 0.24-0.91, p=0.03). No significant association was noted in patients with T3 or T4 disease or beyond the first year of follow up.

It is unclear why this association is there, and the authors don’t provide much rationale. Typically, higher clinical stage disease (T3-4) benefits from centralization of care, but in this study, the benefit was for lower stage disease (T1-2). Perhaps this is due to poor patient selection for nephrectomy, improper decision to complete partial vs. radical nephrectomy, etc. This is somewhat highlighted in the initial demographic differences.

However, it is unclear if this is cancer-specific survival or overall survival. Worse 1-year CSS for stage T1-2 disease seems difficult to believe, as these patients, even with local recurrence, are unlikely to die of disease within the first year.

Further data and explanation is needed to confirm their findings.
tratification model to design a surveillance protocol after five years post-surgery, as the recurrence risk is the same across risk categories.

Speaker: R.C.J. Hsu

Co-Author(s): Barclay M., Lyratzopoulos G., Gnanapragasam V., Armitage J.

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark