ASCO GU 2021: Bench to Bedside: Critical Pathways in Renal Cell Carcinoma – Cure the Cancer or Avoid Dialysis? Helping Decide
Using data from a 12-year case-control retrospective look at claims data in Taiwan,1 she noted that the incidence of end-stage kidney disease was 4.05% in 2940 patients compared to 0.68% in 25,520 control cases. Cases and controls were matched by age, gender, location, occupation, income, and baseline medical comorbidities such as hypertension and diabetes. This translated to a hazard ratio for end-stage kidney disease of 5.63 (95% CI 4.37 – 7.24). The question remains whether kidney disease is caused by renal cell carcinoma (RCC) treatment, or develops concomitantly and in an unrelated fashion. This is partially explained by the fact that RCC and chronic kidney disease have similar risk factors such as age, tobacco use, obesity, diabetes, and hypertension. The prevalence of CKD is quite high in RCC patients even prior to surgical or systemic management, with somewhere between 11-32% of patients with a renal mass having CKD at baseline. Treatment does have an impact on the risk of CKD. Patients with baseline albuminuria have an increased risk of CKD after nephrectomy. Post-operative acute kidney injury is also associated with a ~4.2 fold higher risk of new-onset CKD. Less invasive surgery such as with partial nephrectomy has is associated with a lower long-term risk of CKD.
CKD matters because it is associated with a higher risk of cardiovascular death overall, and patients with ESKD have a decreased life expectancy – in one study from 1998 the 5-year survival of ESKD patients was between the life expectancy of patients with colon cancer and lung cancer. The quality of life of patients on dialysis is poor as they suffer from many symptoms such as fatigue, muscle cramps, dyspnea, dizziness, nausea, and decreased appetite.
Unfortunately, patients with ESKD and renal cancer are not immediately eligible for transplant even if managed with definitive therapy. RCC is defined as a tumor with a high recurrence rate, and therefore, patients with early-stage RCC that is in remission must still wait 2 years prior to transplant and must wait 5 years if the primary tumor is “large and invasive”. As noted before, given the mortality risk on dialysis, many patients who might be otherwise eligible for transplant will not survive long enough to receive a transplant.
Dr. Hu ended by discussing that nephrologists and oncologists have common goals for patients, to try and cure the cancer and minimize the morbidity of treatment. To this end, surgeons can assess baseline CKD risk factors, consider nephron-sparing procedures if possible, and consult nephrology early. A non-tumor renal biopsy may be helpful in diagnosing underlying conditions that can be treated. Nephrologists can help optimize modifiable CKD risk factors, and facilitate the referral for renal transplantation.
Presented by: Susie L. Hu, MD, FASN, BRCU, Brown Medicine Division of Kidney Disease and Hypertension, East Providence, RI
Written by: Alok Tewari, MD, PhD, Medical Oncologist at the Dana-Farber Cancer Institute, during the 2021 American Society of Clinical Oncology Genitourinary Cancers Symposium (#GU21), February 11th-February 13th, 2021
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