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65 COMPARATIVE EFFECTIVENESS OF PARTIAL VERSUS RADICAL NEPHRECTOMY IN THE TREATMENT OF PATIENTS WITH EARLY-STAGE KIDNEY CANCER
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THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
General & Epidemiological Trends & Socioeconomics: Evidence-Based Medicine & Outcomes II Moderated Poster Saturday, May 19, 2012
3:30 PM-5:30 PM
65 COMPARATIVE EFFECTIVENESS OF PARTIAL VERSUS RADICAL NEPHRECTOMY IN THE TREATMENT OF PATIENTS WITH EARLY-STAGE KIDNEY CANCER Hung-Jui Tan*, Edward C. Norton, Zaojun Ye, Khaled S. Hafez, Ann Arbor, MI; John L. Gore, Seattle, WA; David C. Miller, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Despite its many flaws, the EORTC trial demonstrated improved survival for patients with small kidney cancers treated with radical nephrectomy (RN), generating new uncertainty regarding the comparative effectiveness of partial nephrectomy (PN) versus RN. Using an instrumental variable (IV) approach to balance both measured and unmeasured covariates among treatment groups, we sought to clarify this issue by comparing survival outcomes after PN versus RN in a population-based cohort of patients whose treatment more accurately reflects contemporary practice trends and surgical techniques. METHODS: Using linked SEER-Medicare data, we identified patients treated with PN or RN for clinical stage T1a kidney cancer from 1992 through 2007. We selected differential distance to a PN provider as our IV; we defined this as the distance from the patient’s residence to the nearest provider performing at least 1 PN in the year of treatment minus the distance from the patient’s residence to the nearest surgeon performing any kidney cancer surgery. After confirming that our IV was highly correlated with the treatment (i.e., PN), but not independently associated with the outcome (i.e., survival), we fit a two-stage residual inclusion model to estimate the treatment effect of PN on overall and cancer-specific survival, adjusting for both measured (e.g., age, comorbidity, post-operative complications) and unmeasured covariates. RESULTS: We identified 1,925 (27.0%) and 5,213 (73.0%) patients treated with PN and RN, respectively. During a median follow-up of 58 months (range 0-215), 2,651 patients died, including 230 from kidney cancer. Patients treated with PN had a significantly lower risk of death (0.54 HR, 95% CI 0.34-0.85), corresponding to a predicted survival advantage of 6%, 12%, and 16% at 2-, 5-, and 8-years post-treatment (p⬍0.05) (Figure). This finding was most notable among patients ⱕ 75 years old (HR 0.42, 95% CI 0.22-0.79) or with comorbid conditions (HR 0.40, 95% CI 0.22-0.76). We noted no difference in cancer-specific survival (HR 0.69, 95% CI 0.15-3.24). CONCLUSIONS: For patients with early-stage kidney cancer, treatment with PN rather than RN yields better overall survival. This survival benefit is most pronounced for younger patients and those with comorbid health conditions.
Source of Funding: None
66 COMPARATIVE EFFECTIVENESS OF SURGICAL THERAPIES FOR BENIGN PROSTATIC HYPERPLASIA Sean Elliott*, Minneapolis, MN; Xinhua Yu, Memphis, TN; Seth Strope, St Louis, MO; Alexander McBean, Minneapolis, MN INTRODUCTION AND OBJECTIVES: There has been rapid adoption of new minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) in the last decade. The gold standard, transurethral resection of the prostate (TURP), is currently performed in a minority of cases. By describing the risk of retreatment and urologic complications of treatment, we sought to compare the effectiveness of TURP to transurethral microwave therapy (TUMT), needle ablation (TUNA), laser vaporization and laser coagulation. METHODS: Using the 100% Medicare files from 2001 through 2007, we identified claims for the above-listed BPH surgeries. Age, race, zip code-level income and education, and year of surgery were documented for each procedure. We compared the frequency of claims for treatment of surgical complications (e.g. incision of bladder neck contracture or cystoscopy and fulguration) through 2008, using chi square. We measured the cumulative incidence and adjusted hazard of repeat BPH surgery of any type through 2008. RESULTS: 624,319 men underwent BPH surgery. Mean follow-up was 3.6 years. TURP was the most common procedure (52.3%). The most common complication was urethral stricture (4.4%). It was most common after TURP (5.7%) and least common after TUMT (2.3%) or TUNA (2.6%; p⬍0.001). Bladder neck contracture occurred in 2.0% (2.6% after TURP, 2.3% after laser coagulation, 1.6% after laser vaporization and ⬍1% after TUMT or TUNA; p⬍0.001). The 5-year Kaplan-Meier estimates of the cumulative incidence of repeat BPH surgery ranged from 8.3% after TURP to 25.8% after TUMT (see Figure). The adjusted risk of repeat BPH surgery was 252% higher after TUMT than TURP (HR⫽3.52, CI 3.46-3.59). The HR of repeat surgery after TUNA was 2.71. It was 2.98 after laser coagulation and 2.11 after laser vaporization. Results did not differ when stratifying by time period of the surgery: 2001-03, 2004-05, or 2006-07. CONCLUSIONS: TURP has a slightly increased risk of complications including urethral stricture and bladder neck contracture but a dramatically lower risk of repeat BPH surgery compared to minimally invasive surgeries. At 5 years, repeat BPH surgery occurs in approximately 20% of men after initial treatment with TUMT, TUNA or laser therapies.
THE JOURNAL OF UROLOGY姞
Vol. 187, No. 4S, Supplement, Saturday, May 19, 2012
General & Epidemiological Trends & Socioeconomics: Evidence-Based Medicine & Outcomes II Moderated Poster Saturday, May 19, 2012
3:30 PM-5:30 PM
65 COMPARATIVE EFFECTIVENESS OF PARTIAL VERSUS RADICAL NEPHRECTOMY IN THE TREATMENT OF PATIENTS WITH EARLY-STAGE KIDNEY CANCER Hung-Jui Tan*, Edward C. Norton, Zaojun Ye, Khaled S. Hafez, Ann Arbor, MI; John L. Gore, Seattle, WA; David C. Miller, Ann Arbor, MI INTRODUCTION AND OBJECTIVES: Despite its many flaws, the EORTC trial demonstrated improved survival for patients with small kidney cancers treated with radical nephrectomy (RN), generating new uncertainty regarding the comparative effectiveness of partial nephrectomy (PN) versus RN. Using an instrumental variable (IV) approach to balance both measured and unmeasured covariates among treatment groups, we sought to clarify this issue by comparing survival outcomes after PN versus RN in a population-based cohort of patients whose treatment more accurately reflects contemporary practice trends and surgical techniques. METHODS: Using linked SEER-Medicare data, we identified patients treated with PN or RN for clinical stage T1a kidney cancer from 1992 through 2007. We selected differential distance to a PN provider as our IV; we defined this as the distance from the patient’s residence to the nearest provider performing at least 1 PN in the year of treatment minus the distance from the patient’s residence to the nearest surgeon performing any kidney cancer surgery. After confirming that our IV was highly correlated with the treatment (i.e., PN), but not independently associated with the outcome (i.e., survival), we fit a two-stage residual inclusion model to estimate the treatment effect of PN on overall and cancer-specific survival, adjusting for both measured (e.g., age, comorbidity, post-operative complications) and unmeasured covariates. RESULTS: We identified 1,925 (27.0%) and 5,213 (73.0%) patients treated with PN and RN, respectively. During a median follow-up of 58 months (range 0-215), 2,651 patients died, including 230 from kidney cancer. Patients treated with PN had a significantly lower risk of death (0.54 HR, 95% CI 0.34-0.85), corresponding to a predicted survival advantage of 6%, 12%, and 16% at 2-, 5-, and 8-years post-treatment (p⬍0.05) (Figure). This finding was most notable among patients ⱕ 75 years old (HR 0.42, 95% CI 0.22-0.79) or with comorbid conditions (HR 0.40, 95% CI 0.22-0.76). We noted no difference in cancer-specific survival (HR 0.69, 95% CI 0.15-3.24). CONCLUSIONS: For patients with early-stage kidney cancer, treatment with PN rather than RN yields better overall survival. This survival benefit is most pronounced for younger patients and those with comorbid health conditions.
Source of Funding: None
66 COMPARATIVE EFFECTIVENESS OF SURGICAL THERAPIES FOR BENIGN PROSTATIC HYPERPLASIA Sean Elliott*, Minneapolis, MN; Xinhua Yu, Memphis, TN; Seth Strope, St Louis, MO; Alexander McBean, Minneapolis, MN INTRODUCTION AND OBJECTIVES: There has been rapid adoption of new minimally invasive surgical therapies for benign prostatic hyperplasia (BPH) in the last decade. The gold standard, transurethral resection of the prostate (TURP), is currently performed in a minority of cases. By describing the risk of retreatment and urologic complications of treatment, we sought to compare the effectiveness of TURP to transurethral microwave therapy (TUMT), needle ablation (TUNA), laser vaporization and laser coagulation. METHODS: Using the 100% Medicare files from 2001 through 2007, we identified claims for the above-listed BPH surgeries. Age, race, zip code-level income and education, and year of surgery were documented for each procedure. We compared the frequency of claims for treatment of surgical complications (e.g. incision of bladder neck contracture or cystoscopy and fulguration) through 2008, using chi square. We measured the cumulative incidence and adjusted hazard of repeat BPH surgery of any type through 2008. RESULTS: 624,319 men underwent BPH surgery. Mean follow-up was 3.6 years. TURP was the most common procedure (52.3%). The most common complication was urethral stricture (4.4%). It was most common after TURP (5.7%) and least common after TUMT (2.3%) or TUNA (2.6%; p⬍0.001). Bladder neck contracture occurred in 2.0% (2.6% after TURP, 2.3% after laser coagulation, 1.6% after laser vaporization and ⬍1% after TUMT or TUNA; p⬍0.001). The 5-year Kaplan-Meier estimates of the cumulative incidence of repeat BPH surgery ranged from 8.3% after TURP to 25.8% after TUMT (see Figure). The adjusted risk of repeat BPH surgery was 252% higher after TUMT than TURP (HR⫽3.52, CI 3.46-3.59). The HR of repeat surgery after TUNA was 2.71. It was 2.98 after laser coagulation and 2.11 after laser vaporization. Results did not differ when stratifying by time period of the surgery: 2001-03, 2004-05, or 2006-07. CONCLUSIONS: TURP has a slightly increased risk of complications including urethral stricture and bladder neck contracture but a dramatically lower risk of repeat BPH surgery compared to minimally invasive surgeries. At 5 years, repeat BPH surgery occurs in approximately 20% of men after initial treatment with TUMT, TUNA or laser therapies.