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Re: Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-based Approach
EUROPEAN UROLOGY 69 (2016) 962–966
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-based Approach Stewart-Merrill SB, Thompson RH, Boorjian SA, et al J Clin Oncol 2015;33:4151–7 Experts’ summary: Using a robust series of 2511 patients followed for a median time of 9.0 yr, Stewart-Merrill et al proposed a novel approach that enables a tailored follow-up strategy following surgical resection of clinically localized renal cell carcinoma (RCC). By means of competing risk models incorporating age, Charlson comorbidity index (CCI), pathologic tumor stage, and recurrence location (abdomen, chest, bone, other), the authors determined the points in time at which the patient’s risk of dying from a non-RCC cause exceeded that of recurrence. They found considerable variability in those time points. Among patients with pT1Nx-0 disease who had CCI <1, for example, the risk of non-RCC death began to exceed that of abdominal recurrence at 7 yr for patients aged 50–59 yr, at 2.5 yr for patients aged 60–69 yr, and at 6 mo for patients aged 80 yr. The authors concluded that their competing risks model allows for better prediction and offers an individualized surveillance strategy based on the patient’s health status and cancer characteristics. This risk-adapted approach offers the advantage of forgoing unnecessary follow-up when not needed and prolonging it when necessary but not recommended by current guidelines. Experts’ comments: Patients who undergo surgical resection for RCC differ widely in risk. Pathologic stage, histotype, tumor grade, and performance status are the most established prognostic factors. In a prior report, Stewart et al applied various existing guidelines protocols to an RCC surgical cohort and found that a strategy that follows all patients in a similar fashion indiscriminately in terms of risk would miss up to 64% of recurrences, whereas TNM risk-based follow-up strategies would miss close to 30% of recurrences, mainly because the existing guidelines limit the length of follow-up to 5 yr [1]. In the featured study, Stewart-Merrill et al proposed a competing risks model that takes into account the cancer
characteristics and the patient’s age and existing comorbidities. This model estimates the risk of cancer recurrence versus the risk of non–RCC-related death and thus effectively allows for the adjustment of the duration of cancer surveillance needed for a given patient. Unlike surveillance protocols based on cumulative incidence, the proposed model is dynamic and takes into consideration the amount of follow-up without recurrence as a conditional probability for future recurrences [2]. This novel risk-adapted approach has the potential for both clinical and cost-effectiveness. Although this is an important step forward toward personalized post-treatment surveillance, the current model needs external validation and might gain predictive accuracy by integrating prognostic factors such as histologic subtype, nuclear grade, presence of sarcomatoid features, and better estimation of life expectancy. Conflicts of interest: The authors have nothing to disclose.
References [1] Stewart SB, Thompson RH, Psutka SP, et al. Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines. J Clin Oncol 2014;32:4059–65. [2] Carroll KJ. On the use and utility of the Weibull model in the analysis of survival data. Control Clin Trials 2003;24:682–701.
Daniel P. Nguyena, Karim A. Touijerb,c,* a
Department of Urology, Inselspital, Bern University Hospital, Bern, Switzerland b
Urology Service, Department of Surgery,
Memorial Sloan Kettering Cancer Center, New York, NY, USA c
Weill Cornell Medical College, New York, NY, USA
*Corresponding author. Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 353 East 68th Street, New York, NY 10065, USA. E-mail address: [email protected] (K.A. Touijer).
http://dx.doi.org/10.1016/j.eururo.2016.02.008
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Words of Wisdom Re: Oncologic Surveillance After Surgical Resection for Renal Cell Carcinoma: A Novel Risk-based Approach Stewart-Merrill SB, Thompson RH, Boorjian SA, et al J Clin Oncol 2015;33:4151–7 Experts’ summary: Using a robust series of 2511 patients followed for a median time of 9.0 yr, Stewart-Merrill et al proposed a novel approach that enables a tailored follow-up strategy following surgical resection of clinically localized renal cell carcinoma (RCC). By means of competing risk models incorporating age, Charlson comorbidity index (CCI), pathologic tumor stage, and recurrence location (abdomen, chest, bone, other), the authors determined the points in time at which the patient’s risk of dying from a non-RCC cause exceeded that of recurrence. They found considerable variability in those time points. Among patients with pT1Nx-0 disease who had CCI <1, for example, the risk of non-RCC death began to exceed that of abdominal recurrence at 7 yr for patients aged 50–59 yr, at 2.5 yr for patients aged 60–69 yr, and at 6 mo for patients aged 80 yr. The authors concluded that their competing risks model allows for better prediction and offers an individualized surveillance strategy based on the patient’s health status and cancer characteristics. This risk-adapted approach offers the advantage of forgoing unnecessary follow-up when not needed and prolonging it when necessary but not recommended by current guidelines. Experts’ comments: Patients who undergo surgical resection for RCC differ widely in risk. Pathologic stage, histotype, tumor grade, and performance status are the most established prognostic factors. In a prior report, Stewart et al applied various existing guidelines protocols to an RCC surgical cohort and found that a strategy that follows all patients in a similar fashion indiscriminately in terms of risk would miss up to 64% of recurrences, whereas TNM risk-based follow-up strategies would miss close to 30% of recurrences, mainly because the existing guidelines limit the length of follow-up to 5 yr [1]. In the featured study, Stewart-Merrill et al proposed a competing risks model that takes into account the cancer
characteristics and the patient’s age and existing comorbidities. This model estimates the risk of cancer recurrence versus the risk of non–RCC-related death and thus effectively allows for the adjustment of the duration of cancer surveillance needed for a given patient. Unlike surveillance protocols based on cumulative incidence, the proposed model is dynamic and takes into consideration the amount of follow-up without recurrence as a conditional probability for future recurrences [2]. This novel risk-adapted approach has the potential for both clinical and cost-effectiveness. Although this is an important step forward toward personalized post-treatment surveillance, the current model needs external validation and might gain predictive accuracy by integrating prognostic factors such as histologic subtype, nuclear grade, presence of sarcomatoid features, and better estimation of life expectancy. Conflicts of interest: The authors have nothing to disclose.
References [1] Stewart SB, Thompson RH, Psutka SP, et al. Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines. J Clin Oncol 2014;32:4059–65. [2] Carroll KJ. On the use and utility of the Weibull model in the analysis of survival data. Control Clin Trials 2003;24:682–701.
Daniel P. Nguyena, Karim A. Touijerb,c,* a
Department of Urology, Inselspital, Bern University Hospital, Bern, Switzerland b
Urology Service, Department of Surgery,
Memorial Sloan Kettering Cancer Center, New York, NY, USA c
Weill Cornell Medical College, New York, NY, USA
*Corresponding author. Urology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 353 East 68th Street, New York, NY 10065, USA. E-mail address: [email protected] (K.A. Touijer).
http://dx.doi.org/10.1016/j.eururo.2016.02.008