Washington, DC (UroToday.com) In today’s renal cancer session at the 2015 SUO, Dr. Sherri Donat discussed the process that goes into the development of renal cancer follow-up guidelines and critiques of those guidelines. The purpose of guidelines is to provide a framework for follow-up of localized renal neoplasms undergoing active surveillance or following definitive treatment. Moreover, guidelines provide guidance for ongoing evaluation of renal function, use of renal biopsy, timing/type of imaging, and survivorship considerations.
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Considerations specific to imaging include risk of repeat radiation exposure, limitations of each imaging modality, consideration of nephrogenic systemic fibrosis associated w IV gadolinium, and renal insufficiency or contrast allergy with the use of CT contrast.
The panel for renal cancer follow-up guidelines initially convened in 2009, and ultimately reviewed literature from 1999-2011. They included clinical trials, observational studies, and systematic reviews. Following review, extraction, and synthesis of data, guideline statements were formulated based on the level of data. Those that were considered standards featured benefits that were clearly greater or less than the risks. Those that were labeled as options had no difference between benefits and risks.
The group concluded that evaluation should include renal function, serum studies, physical exam, and imaging. Follow-up should be tailored to recurrence risk, comorbidities, and treatment of sequelae. A lack of studies precluded risk stratification beyond staging. Expert opinion determined a balanced course of judicious evaluation that may evolve as treatments evolve and more long-term data is collected.
Following release of the guidelines, a number of articles criticized certain aspects. Stewart and colleagues (JCO 2014) found that the guidelines miss 1/3 of recurrences in their cohort, and that the a large proportion of these were considered to be low risk disease. Strope and colleagues (ASCO/JCO 2014) released a SEER-based study that showed higher rates of imaging were not associated with better OS or CSS after radical or partial nephrectomy. Kim and colleagues (J Urol 2011) published a study of 1500 patients in which there was a 5% rate of local recurrence and 15% rate of metastasis after 5 years, and that longer follow-up may be needed.
Dr. Donat concluded that we need better institutional data, and we may need to eliminate older data with prior stage information from our analyses going forward. An SUO-based databank could be a useful way to accrue patients on a multi-institutional basis. Next, we need to reach a consensus on definitions of all variables, including “recurrence.” Finally, improved quality of prospective data will help us improve guidelines for the follow-up of renal cancer.
Dr. Sherri Donat
Memorial Sloan Kettering Cancer Center
Dr. Nikhil Waingankar, MD. from the Society of Urologic Oncology Meeting - December 2 - 4, 2015 – Washington, DC.
Fox Chase Cancer Center, Philadelphia, PA.