Urologist-level variation in the management of T1a renal cell carcinoma: A population-based cohort study.

OBJECTIVES: Lack of strict indications in current guidelines have led to significant variation in management patterns of small renal masses. The impact of the urologist on the management approach for patients with small renal masses has not been explored previously. MATERIALS AND METHODS: Using the linked Surveillance, Epidemiology, and End Results-Medicare database, patients aged ≥66 years diagnosed with small renal masses from January 1, 2004 to December 31, 2013 were identified and assigned to primary urologists. Mixed-effects logistic models were used to evaluate factors associated with different management approaches, estimate urologist-level probabilities of each approach, assess management variation, and determine urologist impact on choice of approach. RESULTS: A total of 12,402 patients with 2,794 corresponding primary urologists were included in the study. At the individual urologist level, the estimated case-adjusted probability of different approaches varied markedly: nonsurgical management (mean, 12.8%; range, 4.9%-36.1%); thermal ablation (mean, 10.8%; range, 2.4%-66.3%); partial nephrectomy (mean, 30.1%; range, 10.1%-66.6%); and radical nephrectomy (mean, 40.4%; range, 17.7%-71.6%). Compared to patient and tumor characteristics, the primary urologist was a more influential measured factor, accounting for 13.6% (vs. 12.9%), 33.8% (vs. 2.1%), 15.1% (vs. 8.4%), and 13.5% (vs. 4.0%) of the variation in management choice for nonsurgical management, thermal ablation, partial nephrectomy, and radical nephrectomy, respectively. CONCLUSIONS: Significant variation exists in the management of small renal masses and appears to be driven primarily by urologist preference and practice patterns. Our findings emphasize the need for unified guidance regarding management of these masses to reduce unwarranted variation in care.

Socioeconomic determinants of racial disparities in survival outcomes among patients with renal cell carcinoma.

PURPOSE: Racially driven outcomes in cancer are challenging to study. Studies evaluating the impact of race in renal cell carcinoma (RCC) outcomes are inconsistent and unable to disentangle socioeconomic disparities from inherent biological differences. We therefore seek to investigate socioeconomic determinants of racial disparities with respect to overall survival (OS) when comparing Black and White patients with RCC. METHODS: We queried the National Cancer Database (NCDB) for patients diagnosed with RCC between 2004 and 2017 with complete clinicodemographic data. Patients were examined across various stages (all, cT1aN0M0, and cM1) and subtypes (all, clear cell, or papillary). We performed Cox proportional hazards regression with adjustment for socioeconomic and disease factors. RESULTS: There were 386,589 patients with RCC, of whom 46,507 (12.0%) were Black. Black patients were generally younger, had more comorbid conditions, less likely to be insured, in a lower income quartile, had lower rates of high school completion, were more likely to have papillary RCC histology, and more likely to be diagnosed at a lower stage of RCC than their white counterparts. By stage, Black patients demonstrated a 16% (any stage), 22.5% (small renal mass [SRM]), and 15% (metastatic) higher risk of mortality than White patients. Survival differences were also evident in histology-specific subanalyses. Socioeconomic factors played a larger role in predicting OS among patients with SRMs than in patients with metastasis. CONCLUSIONS: Black patients with RCC demonstrate worse survival outcomes compared to White patients across all stages. Socioeconomic disparities between races play a significant role in influencing survival in RCC.

Differential changes in self-reported quality of life in elderly populations after diagnosis of a genitourinary malignancy.

BACKGROUND: The time of cancer diagnosis is a major event during which quality of life (QOL) can be affected and represents a crucial time to identify patients at high risk of decline. We sought to compare the differential effects of the diagnosis of 3 major urologic malignancies on QOL. METHODS: The Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey database was queried for patients who completed a QOL questionnaire (SF-36 or VR-12) before and after a diagnosis of bladder, kidney, or prostate cancer. Primary outcome measures were the mental component summary (MCS), and physical component summary (PCS) scores. Mixed effects linear regression was performed with cancer diagnosis as the primary variable of interest, with race and cardiovascular comorbidity status included as potentially confounding independent variables. RESULTS: There were 3,258 patients with urologic cancers. Both MCS and PCS scores dropped after diagnosis in all disease states. Bladder and kidney cancer patients demonstrated the greatest decline in MCS score (-1.762 points, 95% CI-2.571 to -0.952, P < 0.001) and PCS score (-3.769 points, 95% CI-5.042 to -2.496, P < 0.001), respectively, after adjustment for potential confounders. By contrast, prostate cancer patients demonstrated the smallest decline in both domains. Race and cardiovascular comorbidity status were independently associated with QOL, with an association 2 to 3 times greater than that of cancer diagnosis. CONCLUSIONS: Diagnosis of a urologic cancer was associated with a decline in patient-reported QOL, particularly in those with bladder or kidney cancer. Changes in physical health were more prominent than in mental health. Race and cardiovascular comorbidity status influenced QOL domains to a greater extent than specific urologic cancer diagnosis.

Active Surveillance versus Immediate Intervention for Small Renal Masses: A Cost-Effectiveness and Clinical Decision Analysis.

PURPOSE: Active surveillance (AS) with the possibility of delayed intervention (DI) is emerging as a safe alternative to immediate intervention for many patients with small renal masses (SRMs). However, limited comparative data exist to inform the most appropriate management strategy for SRMs. MATERIALS AND METHODS: Decision analytic Markov modeling was performed to estimate the health outcomes and costs of 4 management strategies for 65-year-old patients with an incidental SRM: AS (with possible DI), immediate partial nephrectomy, radical nephrectomy, and thermal ablation. Mortality, direct medical costs, quality-adjusted life-years, and incremental cost-effectiveness ratios were evaluated over 10 years. RESULTS: The 10-year all-cause mortality was 22.6% for AS, 21.9% for immediate partial nephrectomy, 22.4% for immediate radical nephrectomy, and 23.7% for immediate thermal ablation. At a willingness-to-pay threshold of $100,000/quality-adjusted life-year, AS was the most cost-effective management strategy. The results were robust in univariate, multivariate, and probabilistic sensitivity analyses. Clinical decision analysis demonstrated that the tumor's metastatic potential, patient age, individual preferences, and health status were important factors influencing the optimal management strategy. Notably, if the annual probability of metastatic progression from AS was sufficiently low (under 0.35%-0.45% for most ages at baseline), consistent with the typical metastatic potential of SRMs <2 cm, AS would achieve higher health utilities than the other strategies. CONCLUSIONS: Compared to immediate intervention, AS with timely DI offers a safe and cost-effective approach to managing patients with SRMs. For patients harboring tumors of very low metastatic potential, AS may lead to better patient outcomes than immediate intervention.

Self-reported quality of life as a predictor of mortality in renal cell carcinoma.

BACKGROUND: This study evaluated the utility of self-reported quality of life (QOL) metrics in predicting mortality among all-comers with renal cell carcinoma (RCC) and externally tested the findings in a registry of patients with small renal masses. METHODS: The Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey (SEER-MHOS) captured QOL metrics composed of mental component summary (MCS) and physical component summary (PCS) scores. Regression models assessed associations of MCS and PCS with all-cause, RCC-specific, and non-RCC-specific mortality. Harrell's concordance statistic (the C-index) and the Akaike information criterion (AIC) determined predictive accuracy and parsimony, respectively. Findings were tested in the prospective Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) registry. RESULTS: In SEER-MHOS, 1494 patients had a median age of 73.4 years and a median follow-up time of 5.6 years. Each additional MCS and PCS point reduced the hazard of all-cause mortality by 1.3% (95% CI, 0.981-0.993; P < .001) and 2.3% (95% CI, 0.971-0.984; P < .001), respectively. Models with QOL metrics demonstrated higher predictive accuracy (C-index, 72.3% vs 70.1%) and parsimony (AIC, 9376.5 vs 9454.5) than models without QOL metrics. QOL metrics exerted a greater effect on non-RCC-specific mortality than RCC-specific mortality. External testing in the DISSRM registry confirmed these findings with similar results for all-cause mortality. CONCLUSIONS: Models with self-reported QOL metrics predicted all-cause mortality in patients with RCC with higher accuracy and parsimony than those without QOL metrics. Physical health was a stronger predictor of mortality than mental health. The findings support the incorporation of QOL metrics into prognostic models and patient counseling for RCC.

Spine Surgeon Treatment Variability: The Impact on Costs.

STUDY DESIGN: Cross-sectional analysis. OBJECTIVES: Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients. METHODS: Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts. RESULTS: For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated <100 times/year had significantly lower costs than those who operated >200 times/year (P < .001) and those with 5-15 years of experience had significantly higher costs than those with >15 years (P < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons (P < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs. CONCLUSIONS: Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons.