Psychological Distress Associated with Active Surveillance in Patients Younger than 70 with A Small Renal Mass - Beyond the Abstract

Renal cell carcinoma (RCC) is a commonly diagnosed cancer representing 4.2% of all new cancer cases,1 with almost a third of patients succumbing to the disease.2 The wide use of imaging in healthcare has resulted in 50% of all RCC cases being incidentally diagnosed on imaging as small renal masses (SRMs), corresponding to clinical stage T1a, and being smaller than 4 cm.

Managing SRMs has sparked a whole new management debate, which includes whether a biopsy should be performed as part of the diagnosis process, and how these masses should be treated, ranging from surveillance and focal therapy to partial and radical nephrectomy. Part of this debate stems from the fact that more than 30% of SRMs are, in fact, benign lesions.3

Patient anxiety is real, especially in cancer patients dealing with a potential aggressive disease with a metastatic capability and requiring at times, more than one treatment modality, and strict adherence to an intensive follow-up protocol. Up to 77% of RCC patients have been shown to report anxiety and need for psychological care,4 regardless of the type of treatment received. More importantly, the resulting psychological Distress has been shown to be an important prognostic factor potentially causing lower survival rates.5

The uniqueness of the surveillance modality is that patients are willingly agreeing to monitor their SRM and not pursue active treatment for an unknown duration of time. That is why 50% of patients who ultimately advance from surveillance to surgical treatment, are motivated by anxiety and fear of progression.6

In this study, we compared the psychological Distress at specific predefined disease time points in patients younger than 70 with an SRM and compared the results of patients treated with surveillance to those treated with surgery or focal ablation.

A total of 477 patients were eventually assessed, and a total of 217 patients underwent surveillance, while 260 patients underwent surgery/ablation. Patients treated with surveillance were, on average older but with smaller mean tumor size. Surveillance-treated patients with a biopsy-proven malignant tumor had a worse psychological distress score compared to patients treated with surgery/ablation after biopsy, and at last follow-up. The multivariable linear regression models demonstrated that a one-point increase in the psychological distress score was 2.6 times (95% CI 0.024- 5.236), more likely in patients who had a biopsy-proven malignant tumor, compared to those without a biopsy. In patients who underwent a biopsy demonstrating a malignant tumor, a one-point increase in the psychological distress score was almost 7 times (95% CI 1.997-11.951), more likely in the surveillance group, compared to the surgery/ablation group. No such association was found in patients who did not undergo a biopsy. 

Despite the clear limitations of this study, including its retrospective nature with clear selection bias, this is the first study, to our knowledge, that analyzed and compared psychological Distress among various management strategies in patients with SRMs. Our main take-home message is that surveillance-treated patients with an SRM have a similar psychological distress score as those treated with surgery, throughout the disease continuum. The only difference noted was in surveillance-treated patients with a biopsy-proven malignant tumor, demonstrating worse psychological Distress following the biopsy and at last follow-up. This observation should be shared with patients contemplating active surveillance for their incidentally discovered SRM. Lastly, supportive psychological care should be part of the comprehensive treatment package that these patients should be offered, especially if harboring a biopsy-proven malignant tumor.

Written by: Hanan Goldberg, MD, MSc, SUNY Upstate Medical University, Syracuse, New-York, USA @Goldberghanan


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