Monty Pal: Hi, there. This is Monty Pal, a medical oncologist at City of Hope. I am here today for UroToday's update of renal cell cancer.

Jamie Landman: This is Jamie Landman. Looking forward to another episode of Kidney Cancer Today. Today, we're very lucky to have Dr. Laura Bukavina, a senior resident, and Lee Ponsky, Professor and Chair of Urology Institute, University Hospital Cleveland Medical Center, Case Western Reserve University School of Medicine. They put together a beautiful manuscript, which was published in January 2020 in Urology Practice on renal cysts.

Laura, do you mind giving us a summary of what you put together here?

Laura Bukavina: Thank you so much for having me. I'm happy to discuss this.

We noticed in our hospital system, which is part of Case Western, is that a lot of times we see these consults for benign renal cysts that undergo unnecessary surveillance. We wanted to look within our healthcare system, what happens with these unnecessary costs that a lot of times patients have to pay for. The article, "Superfluous Hospital Expenditure Associated with Unnecessary Renal Cyst Surveillance", looked at 1,100 patients over two years that we're seeing at Nephrology and PCP's office at Case Western. They were diagnosed with Bosniak renal cysts I and II, which, as you know, don't require any surveillance.

Out of those 1,100 patients, we found that about 20% of the patients underwent unnecessary surveillance. That's anything from an ultrasound to a CT to an additional MRI, which, over those two years, for just our community hospital, equaled to about $400,000 of superfluous cost. When applied to the United States as a whole, we believe it's a huge problem and it adds to the significant health cost expenditure in our capita. We felt that this was an important article to discuss right now between urologists, as well as other providers, as we should adhere to strict guidelines and be careful about imaging as it does have significant risks associated with it.

Dr. Ponsky, do you have any other comments?

Lee Ponsky: Yeah, this was an interesting insight into much larger problems in our healthcare system, and there are multiple reasons. I don't think anyone's doing anything wrong. Everyone is well-intended, so it's not a criticism of nephrologists, primary care, or even urologists, who are imaging patients. There are multiple reasons that we could discuss as to why, but it points to a bigger problem that we see often in the healthcare system. For example, if you look at patients who are worked up for hematuria, often by the primary care providers, often they'll order what they believe is the appropriate initial scan, which may be a non-contrast CT scan or a renal ultrasound, and then the patient may see the urologist, partially worked up, not necessarily with the appropriate studies that we would want. The urologists are then often left with the decision as to, do they repeat studies to check the boxes of what they feel is appropriate or do they accept possibly subpar imaging that may have been already ordered?

There is a lot of opportunities for us to be reflective and be honest with ourselves and educate not only ourselves but our colleagues to the appropriate workup and evaluation of different diseases, such as renal cysts.

Jamie Landman: Lee, I couldn't agree with you more. The denominator here is huge. In the article, you quote that there's something around 27 to 33% of people over 50 have cysts and I have seen data showing that at age 50, 50% of people have cysts. As you know, that number goes up. The first question I'll ask you is, how many people in your practice do you see that are sent for simple cysts?

Lee Ponsky: It's hard to say. I don't have the number of how many are sent for simple cysts, but I would tell you that most primary care providers that see any abnormality, even if it's a simple cyst, will often send it to the urologist, just like we may see patients with trace blood on a dipstick showing up for evaluation. I think it's an opportunity for education, but it's not an insignificant number.

Jamie Landman: Absolutely. I'm seeing a ton of either simple cysts, with some of them occasionally large, but asymptomatic and hyperdense cysts, so this is something that is flooding our offices fairly inappropriately. And I agree with you, it's an opportunity for education.

I'm going to ask the converse question of Monty. Monty, you get to see all the bad actors when it comes to kidney cancer. How often do you see a T1a or T1b largely cystic lesion that ends up in your hands because they have metastatic disease?

Monty Pal: Yeah, I have to say it's incredibly infrequent. We occasionally say it's about the discordance between cumulative size and presence of metastasis with diseases like K2 capillary where you can have a very small primary and overall metastatic disease, but that tends to be fairly infrequent.

Jamie Landman: And those don't tend to present with localized disease, at least the ones I've seen often present with mets already.

Monty Pal: You're absolutely right and you and I've shared a number of those patients where the disease is already widely disseminated.

Jamie Landman: Lee, please tell me if you and Laura disagree that, quite frankly, a lot of these cystic cancers, even if they are indeed cancer, are so indolent that they often can stay on active surveillance and not even be treated.

Laura Bukavina: Correct. I can comment on our data specifically, this isn't published, but looking at our data, out of those 1,100 patients, we only had one patient out of those 1,100 that was diagnosed with a simple cyst that went on to progress to some sort of a Bosniak IV several years later. The odds of you having any significant malignancy or metastatic disease is extremely low and certainly doesn't warrant all of the surveillance.

Jamie Landman: Yeah, I think this is a really important point and that's why when I read the article I was so impressed by the impact that it should have.

I'm going to switch gears and ask you about the numbers that I thought were shocking. It seems like there was a huge discrepancy between African Americans and your Caucasian population in terms of followup, which in this case probably put the African American population into the more appropriate care, but it seemed like a really big example of a healthcare disparity.

Laura Bukavina: Correct. This is not unique to urology. This has been reported in colorectal literature as well. This has been reported in breast cancer as well. It's certainly a disparity that still exists and with some parts of our hospital that serve a population with a higher percentage of African Americans and Hispanic population, we see this across the board. It's multifactorial, whether it's difficulty in access to care, whether it's transportation or just difficulty with understanding the need for surveillance. I actually was protective in our study, in getting extra imaging.

Jamie Landman: Right.

Lee Ponsky: But it certainly braises the larger question. While in this situation, the patients who had less surveillance, it was advantageous for them. However, if you would extrapolate that to patients with prostate cancer or even renal masses that may be on active surveillance, it certainly can be detrimental. We all recognize it's a problem, we're doing a number of studies looking at the discrepancies and I would push our colleagues in urology out there, to not only, like ourselves, point out differences and discrepancies but actionable steps that we can do to improve on these changes.

If we were to criticize ourselves, one of the things we often do are point out differences and then hypothesize about what can be done. But not often are we publishing and studying actionable steps that are being done to impact change. That's my call to action, we need to take that next step as educators, start focusing on actionable steps, and not be afraid to report negative outcomes if they don't work either because that is advantageous and helpful for people around the world trying to implement change.

Jamie Landman: I couldn't agree with you more. In that regard, what are you going to be doing with follow up for this one? Because I think the longer-term followup on these cysts, I guess you're not going to follow up the Is and IIs because that would be inappropriate, but for the IIIs and the Bosniak IVs, you're going to follow him up to see what happens? Are you actively surveilling them or are you going to excise or these ablate these?

Lee Ponsky: It depends on the size, first of all. We treat our IIIs and IVs as if they're small renal mass. We'd follow the indications and the guidelines for a small renal mass. We certainly would follow them. In terms of what we're going to do in terms of the educational component, we have to determine that. We can talk to you and I can give you the answer today that we want to do a better job of educating our colleagues about guidelines. I don't have the answer to what the most effective approach to doing that so that we actually see a difference in adherence to appropriate guidelines. I don't know if you have thoughts on that Jamie, on ways that you've seen actional steps to improve.

Jamie Landman: Your publication of the manuscript and our subsequent discussion, hopefully, we'll get plenty of education on the topic.

I don't know how else to disseminate the information. Obviously these things percolate slowly to common practice, but I will go back to the last question because you said you'd follow guidelines. Whether you talk about the European guidelines or the AUA guidelines or NCCN, there's no clear suggestion other than a strong preference towards partial nephrectomies of Bosniak IIIs and even IVs, which I quote a 92% chance of cancer with my patients, which falls into the range you described in your manuscript. Unless somebody is super young or super nervous, I tend to actively surveil these just because they tend not to be aggressive even though they are very often renal cell variants of some sort.

Lee Ponsky: You'll follow them regardless of size? If you had a five-centimeter cystic mass Bosniak IV you'd follow that as well?

Jamie Landman: What are you referring to five centimeters? The cyst or the nodule within it?

Lee Ponsky: The overall cyst.

Jamie Landman: Right. You've opened these up or seen them or cut them out, I'm sure, and usually, the tumor is a little nodule in the wall. I don't think measuring the cyst and using that as a staging or decision-making tool is very useful. If I saw a five-centimeter nodule in a cyst, I absolutely would be concerned. You don't see that that often and I would consider that a T1b and probably cut it out.

But for a six-centimeter cyst that has a one-centimeter nodule in a 75-year-old guy, I probably am going to watch that guy and not be afraid of the size of his cyst. Do you see it differently?

Lee Ponsky: No, I agree with that. There are cysts and there are cysts. If you have a Bosniak IV with fixed septation and multiple nodules throughout, I'm going to look at that differently than a five-centimeter, completely simple cyst with a one-centimeter nodule on the side. There are some differences in how you characterize and I agree with that, but you do individualize it.

Jamie Landman: And Monty, the reason I asked him the question earlier about seeing these, is he sees all the bad actors and I don't think there's anyone in the country who knows bad disease better than he does and he just doesn't see these. They're usually very indolent, even when they are cancers, and the reason I'd love to see more follow-up on your data here is because it has to get into the guidelines and, quite frankly, it has to get into the staging system because they're a different player altogether.

Monty Pal: Laura and Lee, thank you so much for joining us for Kidney Cancer Today. If you have any further follow-up on this, we'd love to get you back on because this is a fascinating and important topic and we're very grateful for your joining us.

Lee Ponsky: We appreciate the opportunity.

Laura Bukavina: Thank you so much for having us.

Jamie Landman: This is Jamie Landman with Monty Pal saying goodbye and thanks for another episode of Kidney Cancer Today.