The National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). These guidelines are formulated recommendations that are either generalized or based on tumor stage or integrated prognostic algorithms. While both have their purpose, the guidelines are not uniform and there is no definitive evidence to clarify which protocol is the most effective.
In a recent study in the Journal of Clinical Oncology, Mayo Clinic researchers, first author Bradley Leibovich, M.D., assess the ability of the guidelines to capture RCC recurrences after surgery when abiding by the prescribed protocols. The team also summarized the total duration of surveillance required to capture 90, 95, and 100 percent of RCC recurrences when using a surveillance design that incorporated location-specific recurrence patterns among risk groups. A 2014 Medicare cost comparison was performed among established guidelines and for the hypothetical situation if surveillance was extended to capture 95 percent of RCC recurrences.
During the study, 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008 were analyzed. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared.
At a median follow-up of 9 years, a total of 1,088 patients experienced a recurrence. Of these, 390 recurrences were detected using 2013 NCCN recommendations, 742 recurrences were detected using 2014 NCCN recommendations, and 728 recurrences were detected using AUA recommendations. To capture 95 percent of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were $1,228.79 using 2013 NCCN, $2,131.52 using 2014 NCCN, and $1,738.31 using AUA guidelines. However, if 95% of LR-partial recurrences were captured, costs would total $9,856.82.
Based on these results, if strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. According to Mayo Clinic researchers, improved surveillance algorithms are needed to balance patient benefits and health care.
Additional Mayo Clinic authors include: Suzanne Stewart, M.D., R. Houston Thompson, M.D., Sarah Psutka, M.D., John Cheville, M.D., Christine Lohse, and Stephen Boorjian, M.D.