Surveillance an Option for Small Renal Masses in the Elderly

Phoebe Starr

March 2013, Vol 4, No 3 - Genitourinary Cancers Symposium

Orlando, FL—Surveillance for small renal masses achieves similar outcomes in the elderly compared with the standard approach of surgery, according to a large retrospective analysis reported at the 2013 Genitourinary Cancers Symposium. These findings suggest that both the costs and the complications associated with surgery can be avoided in elderly patients, especially patients with a shorter life expectancy and/or comorbid conditions.

The analysis of more than 8300 elderly patients with small renal masses showed that surveillance and surgery each led to a 3% rate of kidney cancer–specific mortality during 59 months of follow-up. However, patients managed with surgery had more deaths from all causes and cardiovascular (CV) complications compared with those managed with surveillance.

“Our analysis shows that physicians can be comfortable telling an elderly patient that the likelihood of dying from kidney cancer is low with both surveillance and surgery, and that kidney surgery is unlikely to extend their lives. This is especially important for an older patient who is not healthy enough to tolerate anesthesia and surgery. However, surgery is still a standard option for healthier older patients with a longer life expectancy,” said lead investigator William C. Huang, MD, Assistant Professor, Uro­logic Oncology, New York University Langone Medical Center, New York City.

The study used the Surveillance, Epidemiology and End Results registry database linked to Medicare claims for patients aged ≥66 years to identify patients who were diagnosed with small renal masses (ie, <4 cm in diameter). A total of 7148 patients had a pathologic diagnosis; 78% underwent surgery, and 22% were managed by surveillance.

At a median follow-up of 59 months, 2078 deaths were reported. The rate of kidney cancer–specific mortality was 3% in each group.

Overall, 21% of the patients died, and 24% experienced a CV event during follow-up. Over time, surveillance was associated with a significantly lower risk of experiencing a CV event compared with surgery (P >.001) and a 49% lower risk of death from any cause.

Patients in the surgical group underwent a variety of surgical procedures, including total and partial nephrectomies. When asked about the link between surgery and CV events, Dr Huang said that even partial removal of kidney tissue could impair kidney function and could cause CV problems, but he noted that this is theoretical.

“Watchful waiting is a reasonable option for elderly patients with small kidney masses. Most of these small tumors are found incidentally on imaging for other reasons. We don’t know which of these lesions will become malignant. We would like to avoid unnecessary surgery in this group of patients. It is important that this study showed no negative impact on increasing kidney cancer mortality with watchful waiting. However, the study showed that surgical intervention increased the risk of cardiovascular events and death,” noted Bruce Roth, MD, Professor of Medicine, Division of Oncology, Washington University, St Louis, MO, an expert who was not involved in the study.