Conditional survival of patients with stage I-III squamous cell carcinoma of the penis: temporal changes in cancer-specific mortality.

PURPOSE: To test the conditional survival that examined the effect of event-free survival on cancer-specific mortality after primary tumour excision (PTE) in patients with squamous cell carcinoma of the penis (SCCP). MATERIALS AND METHODS: Within the SEER database (1998-2015), 2282 stage I-III SCCP patients were identified. Conditional survival estimates were used to calculate cancer-specific mortality (CSM) after event-free survival intervals of 1, 2, 3, and 5 years. Multivariable Cox regression models predicted CSM according to event-free survival. RESULTS: After PTE, 5-year CSM-free rate was 78.0% and increased to 84.6%, 88.1%, 92.0%, and 94.2% in patients who survived ≥ 1, ≥ 2, ≥ 3, and ≥ 5 years. After stratification according to tumour characteristics, 5-year CSM-free rates increased from 85.9 to 95.4%, 79.0 to 97.1%, 78.9 to 90.0%, and from 54.5 to 86.0% in those survived ≥ 5 years, respectively, in T1N0, T2N0, T3N0, and N1-2 patients. In multivariable analyses, T2N0 [hazard ratio (HR) 1.68; p value < 0.001], T3N0 (HR 1.94; p value 0.001), and N1-2 (HR 6.61; p value < 0.001) were independent predictors of higher CSM rate at baseline, relative to T1N0. A decrease in all HRs was assessed over time in patients who survived. Attrition due to CSM was highest in N1-2 cohort and lowest in T1N0. CONCLUSIONS: Conditional survival models showed a direct relationship between event-free survival duration and subsequent CSM in SCCP patients. Even patients with non-organ-confined disease may achieve survival probabilities similar to those with organ-confined disease after at least 5 years of event-free survival since PTE.

Adherence to guideline recommendations for multimodality treatment of patients with pT2-3 M0 non-urothelial carcinoma of the urinary bladder: Temporal trends and survival outcomes.

OBJECTIVES: To analyze contemporary multimodality treatment rates, defined as radical cystectomy plus chemotherapy and/or radiotherapy, for pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients. Additionally, we tested for the effect of multimodality treatment versus radical cystectomy alone on cancer-specific mortality. METHODS: Within the Surveillance, Epidemiology and End Results database (2004-2015), 887 pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients treated with radical cystectomy were identified. Kaplan-Meier plots, and univariable and multivariable Cox regression analyses focused on cancer-specific mortality rates. RESULTS: Squamous cell carcinoma was recorded in 499 (56.3%) patients, neuroendocrine carcinoma in 246 (27.7%) and adenocarcinoma in 142 (16.0%). The highest proportion of multimodality treatment patients was recorded in neuroendocrine carcinoma (69.1%), relative to adenocarcinoma (34.5%) and squamous cell carcinoma (26.4%). A statistically significant annual increase was recorded in multimodality treatment rates in neuroendocrine carcinoma patients (46.7-74.2%, P < 0.01), but not in adenocarcinoma or squamous cell carcinoma patients. The 5-year cancer-specific mortality rate in neuroendocrine carcinoma patients was significantly lower after multimodality treatment versus radical cystectomy alone (37.0% vs 51.5%; P < 0.01), but no statistically significant differences were recorded in both adenocarcinoma (46.1% vs 35.5%; P = 0.8) and squamous cell carcinoma (41.4% vs 31.1%; P = 0.8) patients. In multivariable analyses, for neuroendocrine carcinoma patients, multimodality treatment was an independent predictor of a lower cancer-specific mortality rate (hazard ratio 0.58, P = 0.03). CONCLUSIONS: Multimodality treatment has been increasingly used during the study period in neuroendocrine carcinoma patients, and it has translated into a cancer-specific mortality benefit. This is not the case for other non-urothelial carcinoma of urinary bladder patients, such as adenocarcinoma or squamous cell carcinoma.

Distribution of metastatic sites in patients with prostate cancer: A population-based analysis.

BACKGROUND: There is few data on what constitutes the distribution of metastatic sites in prostate cancer (PCa). The aim of our study was to systematically describe the most common sites of metastases in a contemporary cohort of PCa patients. METHODS: Patients with metastatic PCa were abstracted from the Nationwide Inpatient Sample (1998-2010). Most common metastatic sites within the entire population were described. Stratification was performed according to the presence of single or multiple (≥ 2 sites) metastases. Additionally, we evaluated the distribution of metastatic sites amongst patients with and without bone metastases. RESULTS: Overall, 74,826 patients with metastatic PCa were identified. The most common metastatic sites were bone (84%), distant lymph nodes (10.6%), liver (10.2%), and thorax (9.1%). Overall, 18.4% of patients had multiple metastatic sites involved. When stratifying patients according to the site of metastases, only 19.4% of men with bone metastases had multiple sites involved. Conversely, among patients with lymph nodes, liver, thorax, brain, digestive system, retroperitoneum, and kidney and adrenal gland metastases the proportion of men with multiple sites involved was 43.4%, 76.0%, 76.7%, 73.0%, 52.2%, 60.9%, and 76.4%, respectively. When focusing exclusively on patients with bone metastases, the most common sites of secondary metastases were liver (39.1%), thorax (35.2%), distant lymph nodes (24.6%), and brain (12.4%). CONCLUSIONS: Although the majority of patients with metastatic PCa experience bone location, the proportion of patients with atypical metastases is not negligible. These findings might be helpful when planning diagnostic imaging procedures in patients with advanced PCa.

Survival benefit of definitive therapy in patients with clinically advanced prostate cancer: estimations of the number needed to treat based on competing-risks analysis.

OBJECTIVE: To describe the survival benefit associated with radical prostatectomy (RP), as compared with initial observation, in patients with locally advanced prostate cancer (PCa). PATIENTS AND METHODS: Overall, 1382 patients with locally advanced PCa treated with RP or initial observation between 1995 and 2009 were identified from the Surveillance, Epidemiology and End Results Medicare insurance programme-linked database. Patients were matched using propensity-score methodology, then 10-year cancer-specific mortality (CSM) rates were estimated and the number needed to treat (NNT) was calculated. Competing-risks regression analyses tested the relationship between treatment type and CSM. RESULTS: Overall, the 10-year CSM rates were 11.8 and 19.3% for patients treated with RP and initial observation, respectively (P < 0.001). The corresponding 10-year NNT was 13. The 10-year CSM rates for the same treatment groups were 8.9 vs 13.9%, respectively, for Gleason score ≤7, 16.8 vs 27.8%, respectively, for Gleason score 8-10, 10.1 vs 15.8%, respectively, for clinical stage T3a, and 17.0 vs 29.3%, respectively, for T3b/T4, respectively (all P ≤ 0.04). The corresponding NNTs were 20, 9, 17 and 8, respectively. In multivariable analyses, RP was an independent predictor of more favourable CSM rates in all categories (all P ≤ 0.04). In separate sensitivity analyses, no differences were recorded when patients treated with radiotherapy were compared with those receiving RP (P = 0.4). Conversely, patients undergoing initial observation had a higher risk of CSM compared with those treated with radiotherapy (P = 0.03). CONCLUSIONS: RP leads to a significant survival advantage compared with observation in patients with locally advanced disease. The highest benefit was observed in patients with T3b/T4 and Gleason score 8-10 disease.

Extent of lymphadenectomy does not improve the survival of patients with renal cell carcinoma and nodal metastases: biases associated with the handling of missing data.

UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: A recent population-based analysis suggested a potential survival benefit with respect to performing lymph node dissection at nephrectomy in node-positive patients with RCC. The findings of the present study failed to corroborate the association of a survival benefit with the performance of lymph node dissection at nephrectomy. OBJECTIVE: Previous studies showed no survival benefit with respect to performing lymph node dissection (LND) at nephrectomy, whereas a recent population-based analysis suggested otherwise, although the latter relied on imputation. To reconcile the findings of that study by critically evaluating the handling of missing data. PATIENTS AND METHODS: Study participants comprised patients diagnosed with non-metastatic renal cell carcinoma (RCC) of all stages who underwent LND at nephrectomy (n = 10 596). Multivariable Cox regression models were performed to predict cancer-specific mortality (CSM), where the primary variable of interest was the extent of LND. To examine differences in approaches with respect to handling missing data, separate analyses were performed: (i) imputed population; (ii) exclusion of patients with missing data; and (iii) inclusion of patients with missing data as a sub-category. RESULTS: Overall, 2916 (28%) patients had missing tumour grade. In multivariable analyses, our findings showed that increasing the extent of LND was associated with a significant protective effect on CSM in patients with pN1 after imputation (hazard ratio [HR], 0.82; P = 0.04). By contrast, the extent of LND was no longer significantly associated with a lower risk of CSM after excluding patients with a missing tumour grade (HR, 0.83; P = 0.1) or when including patients with missing tumour grade as a sub-category (HR, 0.82; P = 0.05). CONCLUSIONS: The findings of the present study failed to corroborate the association of a survival benefit with increasing extent of LND at nephrectomy. The different methodologies employed to account for missing data may introduce important biases. Such considerations are non-negligible with respect to the interpretation of results for investigators who rely on administrative cohorts.

Benefit in regionalisation of care for patients treated with radical cystectomy: a nationwide inpatient sample analysis.

OBJECTIVE: To quantify in absolute terms the potential benefit of regionalisation of care from low- to high-volume hospitals. PATIENTS AND METHODS: Patients with a primary diagnosis of bladder cancer treated with radical cystectomy (RC) were identified within the Nationwide Inpatient Sample, a retrospective observational population-based cohort of the USA, between 1998 and 2009. Intraoperative and postoperative complications, blood transfusions, prolonged length of stay, and in-hospital mortality rates represented the outcomes of interest. Potentially avoidable outcomes were calculated by subtracting predicted rates (i.e. estimated outcomes if care was delivered at a high-volume hospital) from observed rates (i.e. actual observed outcomes after care delivered at a low-volume hospital). Multivariable logistic regression models and number needed to treat were generated. RESULTS: Patients treated at high-volume hospitals had lower odds of complications during hospitalisation than those treated in low-volume hospitals. Potentially avoidable intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalisation, and in-hospital mortality rates were 0.6, 7.4, 2.8, 9.4, and 2.0%, respectively. This corresponds to a number needed to redirect from low- to high-volume hospitals in order to avoid one adverse event of 166, 14, 36, 11 and 50, respectively. CONCLUSION: This is the first report to quantify the potential benefit of regionalisation of RC for muscle-invasive bladder cancer to high-volume hospitals.

Benefit in regionalization of care for patients treated with nephrectomy: a Nationwide Inpatient Sample.

PURPOSE: To provide in absolute terms a quantification of regionalization of care from low- to high-volume hospitals in patients treated with nephrectomy for non-metastatic renal cell carcinoma. METHODS: Relying on the Nationwide Inpatient Sample, 48,172 patients with non-metastatic renal cell carcinoma undergoing nephrectomy were identified. All analyses focused on five specific endpoints: intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalization, and in-hospital mortality. First, multivariable logistic regression models for prediction of the aforementioned endpoints were fitted among high-volume hospitals treated patients. Second, obtained coefficients from such models were applied onto low-volume hospitals treated individuals. Potentially avoidable events were computed through differences between observed and predicted adverse events. The number needed to treat was generated. RESULTS: Low-volume hospitals treated individuals were between 11 and 28 % more likely to succumb to an adverse outcome (all P < 0.001). Differences between observed and predicted adverse outcome rates were all in favor of high-volume hospitals, except for in-hospital mortality. Potentially avoidable intraoperative complications, postoperative complications, blood transfusions, prolonged hospitalization, and in-hospital mortality rates were 1.4, 5.6, 7.6, 24.0, and 0.7 %, respectively. Thus, for every 71, 18, 13, 4, and 143 nephrectomies that are redirected to high-volume hospitals, 1 intraoperative complication, postoperative complication, blood transfusion, prolonged hospitalization, and in-hospital mortality could be potentially avoided. CONCLUSIONS: Regionalization from low- to high-volume hospitals for patients undergoing a nephrectomy is associated with important benefits, for both the payer and patient's perspectives.

Partial and radical nephrectomy provide comparable long-term cancer control for T1b renal cell carcinoma.

OBJECTIVES: To examine utilization rates of partial nephrectomy relative to radical nephrectomy for T1b renal cell carcinoma in contemporary years, to identify sociodemographic and disease characteristics associated with partial nephrectomy use, and to compare effectiveness of partial versus radical nephrectomy with respect to cancer control. METHODS: Using the Surveillance, Epidemiology, and End Results database, 16,333 patients treated with partial or radical nephrectomy for T1bN0M0 renal cell carcinoma between 1988 and 2008 were identified. Logistic regression models were carried out to identify determinants of partial nephrectomy. Subsequently, cumulative incidence rates of cancer-specific and other-cause mortality between partial and radical nephrectomy were assessed, within the matched cohort. Furthermore, competing-risks regression analyses were used for prediction of cancer-specific mortality, after adjusting for other-cause mortality, and vice versa. RESULTS: The utilization rate of partial nephrectomy increased from 1.2% in 1988 to 15.9% in 2008 (P < 0.001). Younger individuals, smaller tumors, persons of black race, as well as men, were more likely to be treated with partial nephrectomy in the current cohort (all P ≤ 0.002). In the post-propensity cohort, the 5- and 10-year cancer-specific mortality rates were 4.4 and 6.1% for partial versus 6.0 and 10.4% for radical nephrectomy, respectively (P = 0.03). Competing-risks regression analyses showed that nephrectomy type was not statistically significantly associated with cancer-specific mortality, even after adjusting for other-cause mortality (hazard ratio 0.89, P = 0.5). CONCLUSIONS: Despite providing a comparable cancer control, the use of partial over radical nephrectomy for T1b renal cell carcinoma in USA has remained limited in recent years.

Fuhrman grade [corrected] has no added value in prediction of mortality after partial or [corrected] radical nephrectomy for chromophobe renal cell carcinoma patients.

Our objective was to test whether Fuhrman grade [corrected] (FG) is applicable in the context of chromophobe renal cell carcinoma patients treated with partial and radical nephrectomy. Patients (n=1862) with chromophobe renal cell carcinoma treated with partial and radical nephrectomy were identified within the Surveillance, Epidemiology, and End Results (1988-2008). Univariable and multivariable Cox regression analyses were fitted to predict cancer-specific mortality. Discriminant properties were assessed for the conventional four-tiered FG scheme. Additionally, discrimination of the three-tiered FG scheme (1-2 vs 3 vs 4) and the two-tiered FG scheme (1-2 vs 3-4) was also assessed. The statistical significance of the differences in accuracy estimates was compared using the Mantel-Haenszel test. A total of 65 of the 1862 died of the disease. The overall 5-year cancer-specific mortality-free survival rate was 94.8% (95% confidence interval: 93.5-96.2). In univariable analyses, none of the FG strata were significantly associated with cancer-specific mortality. Furthermore, FG was less informative (63%) than tumor size (72%) and tumor stage (69%), using measures of discrimination in univariable analyses. After accounting for all covariates, prediction of 5-year cancer-specific mortality was 79.0% vs 80.3% accurate, respectively, with vs without the consideration of FG (P=0.01). Similar discrimination estimates were obtained for the modified three-tiered FG scheme (78.5%; P=0.009) and the modified two-tiered FG scheme (79.5%; P=0.02). In conclusion, FG is not an informative predictor of prognosis, defined as cancer-specific mortality, after partial and radical nephrectomy for chromophobe renal cell carcinoma patients.

A population-based analysis of the effect of marital status on overall and cancer-specific mortality in patients with squamous cell carcinoma of the penis.

PURPOSE: The association between marital status and tumor stage and grade, as well as overall mortality (OM) and cancer-specific mortality (CSM) received little attention in patients with squamous cell carcinoma of the penis (SCCP). METHODS: We relied on the surveillance, epidemiology, and end results (SEER) 17 database to identify patients diagnosed with primary SCCP. Logistic and Cox regression models, respectively, addressed the effect of marital status on the rate of locally advanced disease and its effect on OM and CSM. Covariates consisted of age, race, socioeconomic status, year of surgery, and SEER registries. RESULTS: Between 1988 and 2006, 1,884 patients with SCCP were identified. At surgery, 1,192 (63.3 %) were married and 966 (51.3 %) had locally advanced disease. In multivariable logistic regression models predicting locally advanced disease at surgery, unmarried men had a 1.5-fold higher (p < 0.001) risk than others. In multivariable Cox models predicting CSM, marital status had no effect [hazard ratio (HR) = 1.3, p = 0.1]. Finally, in multivariable Cox models predicting OM, unmarried men had a 1.3-fold higher (p = 0.001) risk than others. CONCLUSION: Unmarried men tend to present with less favorable disease stage at SCCP. Moreover, unmarried men tend to live less long than their married counterparts. However, marital status has no effect on CSM.

Robot-assisted versus open radical prostatectomy: the differential effect of regionalization, procedure volume and operative approach.

PURPOSE: The use of robot-assisted radical prostatectomy has increased rapidly despite the absence of randomized, controlled trials showing the superiority of this approach. While recent studies suggest an advantage for perioperative complication rates, they fail to account for the volume-outcome relationship. We compared perioperative outcomes after robot-assisted and open radical prostatectomy, while considering the impact of this established relationship. MATERIALS AND METHODS: Using the NIS (Nationwide Inpatient Sample), we abstracted data on patients treated with radical prostatectomy in 2009. Univariable and multivariable logistic regression analyses were done to compare the rates of blood transfusion, intraoperative and postoperative complications, prolonged length of stay, increased hospital charges and mortality between robot-assisted and open radical prostatectomy overall and across volume quartiles. RESULTS: An estimated 77,616 men underwent radical prostatectomy, including a robot-assisted and an open procedure in 63.9% and 36.1%, respectively. Low volume centers averaged 26.2 robot-assisted and 5.2 open cases, while very high volume centers averaged 578.8 robot-assisted and 150.2 open cases. Overall, patients treated with the robot-assisted procedure experienced a lower rate of adverse outcomes than those treated with the open procedure for all measured categories. Across equivalent volume quartiles robot-assisted radical prostatectomy outcomes were generally favorable. However, the open procedure at high volume centers resulted in a lower postoperative complication rate (OR 0.59, 95% CI 0.46-0.75), elevated hospital charges (OR 0.75, 95% CI 0.64-0.87) and a comparable blood transfusion rate (OR 1.38, 95% CI 0.93-2.02) relative to the robot-assisted procedure at low volume centers. CONCLUSIONS: Regionalization has occurred to a greater extent for robot-assisted than for open radical prostatectomy with an associated benefit in overall outcomes. Nonetheless, low volume institutions experienced inferior outcomes relative to the highest volume centers irrespective of approach. These findings demonstrate the importance of accounting for hospital volume when examining the benefit of a surgical technique.

Effect of nodal metastases on cancer-specific mortality after cytoreductive nephrectomy.

BACKGROUND: Relatively few reports have described the outcomes of patients with node-positive renal cell carcinoma (RCC) in the presence of distant metastases. We examined the outcomes of these patients in a large population-based cohort and examined the ability of standard risk factors to predict cancer-specific mortality (CSM). METHODS: Using the Surveillance, Epidemiology, and End Results database, 1415 RCC patients with distant metastases undergoing cytoreductive nephrectomy (CNT) were identified. Univariable and multivariable analyses addressed CSM to identify independent predictors of CSM. First, the effect of nodal disease on CSM and overall mortality (OM) was estimated in patients with metastatic disease (N0M1 vs. N1M1). Then, we examined the effect of the number of removed nodes and the number of positive nodes on CSM to quantify the effect on mortality, if any, of the increasing burden of nodal disease. RESULTS: Actuarial survival estimates demonstrated that for patients with nodal disease 40.2, 23.5 and 11.5 % of patients survived at 12, 24 and 60 months after nephrectomy. In Kaplan-Meier analyses, patients with N1M1 disease had a significantly worse CSM when compared to patients with N0M1 disease (log rank p < 0.001). In multivariable analyses, N1M1 had a 68 and 69 % increase in CSM and OM (vs. N0M1 disease) while, for every additional positive node, CSM and OM increased by 5.1 and 5.6 %. CONCLUSIONS: In patients undergoing CNT, the burden of nodal disease is an independent predictor of CSM, with an incremental effect of every additional positive node.

In-hospital mortality and failure-to-rescue rates after radical cystectomy.

OBJECTIVE: To show the underlying variability in peri-operative mortality after radical cystectomy (RC) by analysing failure-to-rescue (FTR) rates, i.e. deaths after complications. MATERIALS AND METHODS: Patients undergoing RC for non-metastatic bladder cancer (BCa) were identified from the Nationwide Inpatient Sample, 1999-2009, resulting in a weighted estimate of 79,972 patients. The FTR rates were assessed according to patient and hospital characteristics, as well as complication type. Generalized linear regression analyses were performed. RESULTS: Overall, 26,740 patients had a complication, corresponding to a FTR rate of 5.5%. Septicaemia (odds ratio [OR]: 13.41, P < 0.001) and cardiac (OR: 3.97, P < 0.001), wound-related (OR: 2.12, P < 0.001), genitourinary (OR: 1.62, P = 0.045) and haematological (OR: 1.78, P = 0.008) complications were associated with FTR. Older age (OR: 1.05, P < 0.001), increasing comorbidities (OR: 1.33, P < 0.001), Medicare (OR: 1.52, P = 0.016), and Medicaid insurance status (OR: 2.10, P = 0.029) were associated with higher odds of FTR. Conversely, increasing hospital volume (OR: 0.992, P = 0.014) reduced the odds of FTR. CONCLUSIONS: Whereas both patient and hospital characteristics were associated with increased odds of FTR, the occurrence of septicaemia and cardiac complications were the most strongly associated with a higher risk of in-hospital mortality.

Comparison of partial vs radical nephrectomy with regard to other-cause mortality in T1 renal cell carcinoma among patients aged ≥75 years with multiple comorbidities.

OBJECTIVE: To quantify the effect of partial nephrectomy (PN) vs radical nephrectomy (RN) on other-cause mortality (OCM) in elderly patients with localized renal cell carcinoma (RCC) and/or multiple comorbidities. METHODS: Using the Surveillance, Epidemiology, and End Results Medicare-linked database, patients with T1 RCC, aged ≥75 years, or who had ≥2 comorbidities, were identified (1988-2005). To adjust for inherent differences between treatment types, propensity-based matched analyses were performed. Competing-risks regression analyses for prediction of OCM were assessed according to treatment type. The effect of PN and RN on OCM was examined in three sub-groups: patients aged ≥75 years; patients with ≥2 comorbidities; and patients aged ≥75 years with ≥2 comorbidities. RESULTS: After propensity-based matched analyses and adjustment for all covariates, PN was found to exert a protective effect relative to RN with respect to OCM in all patients (hazard ratio [HR]: 0.84, P = 0.048). In subanalyses, no difference was recorded between PN and RN in patients who were aged ≥75 years (HR: 0.83, P = 0.2), with ≥2 baseline comorbidities at diagnosis (HR: 0.83, P = 0.1), or in patients who were aged ≥75 years and who had ≥2 baseline comorbidities (HR: 0.77, P = 0.2). CONCLUSIONS: Some elderly patients and/or those with multiple comorbidities at diagnosis may not benefit from PN with respect to OCM. After rigorous patient selection, alternative treatment options could be considered.

Sociodemographic disparities in the treatment of small renal masses.

OBJECTIVE: To examine the presence of specific sociodemographic disparities in the treatment of individuals with small renal masses. PATIENTS AND METHODS: Patients diagnosed with pT1aN0M0 renal cell carcinoma (RCC) were identified from the Surveillance, Epidemiology, and End Results database (years 1988-2008). Treatment type was stratified into non-surgical and surgical management and the group of patients who underwent surgical intervention was further stratified into those who underwent partial nephrectomy (PN) and those who underwent radical nephrectomy (RN). The main variables of interest were race and gender, as well as family income and poverty and education levels. Temporal trend analyses and logistic regression models were performed. RESULTS: Of 26,468 patients with T1aN0M0 RCC, 2797 (10.6%) were non-surgically managed and 23,671 (89.4%) underwent surgery. Of the latter, 14,705 (62.1%) underwent RN and 8966 (37.9%) PN. In multivariable analyses, black patients were 23% more likely to be non-surgically managed than other ethnic groups, and if surgically managed, were 20% less likely to undergo PN (both P ≤ 0.007). Men were 19% more likely than women to be non-surgically managed, but remained 14% more likely to receive a PN (both P < 0.001). Treatment disparities according to income, education and poverty level were recorded. Poverty (odds ratio [OR]: 1.002) and education (OR: 0.998) proxies emerged as important determinants of non-surgical management, whereas income (OR: 1.08, all P ≤ 0.02) was a determinant of PN. CONCLUSIONS: Social inequalities regarding access to treatment remain prevalent among patients diagnosed with small renal masses. The persistence of such a phenomenon is a concerning trend which merits further investigation.

Conditional survival after nephrectomy for renal cell carcinoma (RCC): changes in future survival probability over time.

OBJECTIVE: To examine the impact of length of survival on future survival probability, otherwise known as the effect of conditional survival (CS), after nephrectomy (NT) in patients diagnosed with renal cell carcinoma (RCC). PATIENTS AND METHODS: Overall, 42,090 patients with RCC who underwent NT were abstracted from the Surveillance, Epidemiology, and End Results database (1988-2008). Based on cumulative survival estimates, CS rates were derived according to patient and disease characteristics. Separate multivariable Cox regression analyses were performed for the prediction of cancer-specific mortality (CSM), according to 1-, 2-, 3-, 4- and 5-year survival postoperatively. RESULTS: Immediately after surgery, the 5-year cancer-specific survival rate was 83.5%. Amongst patients who survived ≥1, ≥2, ≥3, ≥4, and ≥5 years after NT, the probability rates for surviving an additional 5 years were 87.0, 89.6, 90.9, 92.0 and 92.3%, respectively. Provided that patients survived 1 and 2 years after NT, the probability of being CSM-free for another 5 years increased by +4.1 and 4.3% for stage III and +12.9 and 10.3% for stage IV disease, respectively. Similar observations were recorded for patient age, grade, nodal stage and tumour size, and were confirmed upon multivariable analyses. CONCLUSION: Survival probabilities vary according to length of survival after NT. Specifically, even amongst patients with more advanced disease at surgery, a more favourable prognosis can be achieved after surviving for 1-2 years.

An analysis of patients with T2 renal cell carcinoma (RCC) according to tumour size: a population-based analysis.

OBJECTIVE: To examine the discriminant properties of the most contemporary version of the Tumour-Node-Metastasis (TNM) staging for renal cell carcinoma (RCC) sub-classification of T2 lesions according to a threshold size of 10 cm. Other thresholds were also assessed. PATIENTS AND METHODS: Between 1988 and 2006, within the Surveillance, Epidemiology, and End Results database, patients with T2 N0-2 M0-1 RCC treated with a nephrectomy were abstracted. Tumour size was evaluated according to several thresholds: ≥8, ≥9, ≥10, ≥11, and ≥12 cm. Kaplan-Meier and life tables for cancer-specific mortality (CSM) were computed. Several Cox regression modes were fitted for prediction of CSM, using different thresholds. The predictive accuracy of various thresholds was compared using the area under the curve and methods of calibration. RESULTS: In all, 4963 patients were identified. Kaplan-Meier analyses showed statistically significant CSM-free survival differences between all examined thresholds. In multivariable Cox-regression models, all tested tumour size thresholds emerged as independent predictors of CSM. Of all thresholds, the values of 9 (0.55) and 11 cm (0.55) achieved the highest discrimination in univariable analysis, followed by 10 (0.539), 12 (0.539), and 8 cm (0.531). When the thresholds were combined with all other variables, the 11 cm (0.688) achieved the highest discrimination. CONCLUSION: The discriminant properties of all examined thresholds showed very similar discriminant properties, which brings into questioning whether a dichotomization of pT2 tumours is really necessary.

Rates of open versus laparoscopic and partial versus radical nephrectomy for T1a renal cell carcinoma: a population-based evaluation.

OBJECTIVES: To examine the trends of open and laparoscopic partial nephrectomy and radical nephrectomy according to sociodemographic and tumor characteristics. METHODS: Using the Surveillance, Epidemiology, and End Results Medicare-linked database, 6024 patients diagnosed with T1a renal cell carcinoma were abstracted. Multivariable logistic regression analyses were used for prediction of open radical nephrectomy, open partial nephrectomy, laparoscopic radical nephrectomy and laparoscopic partial nephrectomy. Covariates comprised of patient age, baseline comorbidity status, sex, race, marital status, socioeconomic status, population density, Surveillance, Epidemiology and End Results registry, tumor size, and year of diagnosis. RESULTS: Open radical nephrectomy decreased from 89% in 1988 to 66% in 2005 (P < 0.001), whereas open partial nephrectomy increased from 7% to 29% (P < 0.001). Meanwhile, utilization of either laparoscopic radical nephrectomy or laparoscopic partial nephrectomy remained low. Treatment utilization differed according to Surveillance, Epidemiology, and End Results registries (P < 0.001). Increasing patient age, female sex, low socioeconomic status and unmarried status (all P ≤ 0.003) were predictors of open radical nephrectomy. The utilization rates of laparoscopic radical nephrectomy or laparoscopic partial nephrectomy varied minimally according to the examined characteristics. Older patients or women were significantly more likely to undergo laparoscopic radical nephrectomy, even after adjustment for all covariates (both P ≤ 0.02). CONCLUSIONS: The rising utilization rates of radical nephrectomy are encouraging. Nevertheless, disparities of treatment type still exist. It is of concern that older and female patients are less likely to undergo nephron-sparing surgery, and to have a radical nephrectomy by the laparoscopic approach instead.

Nodal involvement at nephrectomy is associated with worse survival: a stage-for-stage and grade-for-grade analysis.

OBJECTIVES: To examine cancer-specific mortality in patients with nodal metastases relative to patients without nodal involvement at nephrectomy for non-metastatic renal cell carcinoma in a population-based cohort. METHODS: A total of 11 374 non-metastatic renal cell carcinoma patients who underwent a lymph node dissection at nephrectomy were identified using the Surveillance, Epidemiology and End Results database (1988-2008). The 5-year cancer-specific mortality-free survival rates were examined according to the presence or absence of nodal involvement within the entire cohort, and stratified according to pathological tumor stage (pT1 vs pT2 vs pT3 vs pT4) and Fuhrman grade (I vs II vs III vs IV). Cox regression analyses for prediction of cancer-specific mortality were modeled to assess the effect of nodal metastases versus no nodal involvement in the entire population. Finally, separate Cox regression models were fitted within each pathological stage and grade. RESULTS: Overall, 1260 (11%) patients had nodal metastases at nephrectomy. The overall 5-year cancer-specific mortality-free survival rates were 38.4 versus 83.8% in patients with nodal metastases and without nodal metastases, respectively. In multivariable analyses, amongst pT1, pT2, pT3 and pT4, patients with nodal metastases were 6.0-, 3.6-, 3.2- and 2.0-fold, respectively, more likely to die after nephrectomy (all P < 0.001). Similarly, amongst Fuhrman grade I, Fuhrman grade II, Fuhrman grade III and Fuhrman grade IV, patients with nodal metastases were 3.9-, 3.5-, 3.1- and 2.7-fold, respectively, more likely to die of cancer-specific mortality (all P < 0.001). CONCLUSIONS: Nodal involvement is an important determinant of higher cancer-specific mortality after nephrectomy. The detrimental effect of nodal metastases is particularly strong amongst patients with low-stage or low-grade non-metastatic renal cell carcinoma.

Pelvic lymph node dissection for prostate cancer: adherence and accuracy of the recent guidelines.

OBJECTIVES: The 2004 National Comprehensive Cancer Network practice guidelines recommend pelvic lymph node dissection at radical prostatectomy. We sought to examine the adherence to the 2004 National Comprehensive Cancer Network guidelines and to test the their accuracy, as well as the accuracy of the most contemporary National Comprehensive Cancer Network, American Urological Association, and European Association of Urology guidelines to predict lymph node metastases. METHODS: A total of 33 037 radical prostatectomy patients were identified, between 2004 and 2006. Adherence to the 2004 National Comprehensive Cancer Network guidelines was calculated using three clinically plausible cut-offs: 2, 5 and 10%. The accuracy was tested using the area under the curve. RESULTS: Overall, 63% of patients underwent pelvic lymph node dissection. Of those, 61, 49 and 45% were managed according to the 2004 National Comprehensive Cancer Network guideline cut-off of 2, 5 and 10%, respectively. The accuracy of all the examined guidelines ranged from 61% to 71%. The highest accuracy was recorded for the European Association of Urology and the 2004 National Comprehensive Cancer Network cut-off 5% guidelines. The lowest accuracy was recorded for the most contemporary National Comprehensive Cancer Network guideline. CONCLUSIONS: Adherence to the 2004 National Comprehensive Cancer Network guidelines was suboptimal. The accuracy of all the examined guidelines ranged from 61% to 71%. None of the examined guidelines can be regarded as an ideal indication for pelvic lymph node dissection.