Contemporary Cytoreductive Nephrectomy Provides Survival Benefit in Clear-cell Metastatic Renal Cell Carcinoma.

INTRODUCTION: A recent randomized trial questioned the role of cytoreductive nephrectomy in clear-cell metastatic renal cell carcinoma (ccmRCC). We reassessed the effect of cytoreductive nephrectomy on survival in a contemporary population-based ccmRCC cohort. PATIENTS AND METHODS: Within the Surveillance, Epidemiology, and End Results database (2010-2015), we focused on patients with ccmRCC. The primary endpoint consisted of overall mortality. Univariable and multivariable Cox regression models were applied in the overall cohort and in patients who underwent targeted therapy. Sensitivity analyses included 1:1 propensity score matching, 3- and 6-month landmark analyses, incremental survival benefit analyses, and metastases number and location-based stratifications. RESULTS: Of 4062 patients with ccmRCC, 2241 (55.1%) received targeted therapy; cytoreductive nephrectomy was performed in 2226 (54.8%) patients and 1168 (52.1%) patients in the overall and targeted therapy cohorts, respectively. Cytoreductive nephrectomy was associated with lower overall mortality in the overall cohort (median survival, 30 vs. 9 months; hazard ratio [HR], 0.43; P < .001), as well as in the targeted therapy cohort (median survival, 28 vs. 12 months; HR, 0.49; P < .001). In sensitivity analyses, cytoreductive nephrectomy was associated with lower overall mortality after 1:1 propensity score-matching (HR, 0.49; P < .001), in 3- and 6-month landmark analyses (HR, 0.49; P < .001 and HR, 0.51; P < .001, respectively), in metastases number and location-based stratifications, except for exclusive liver metastases, as well as in all incremental benefit analyses. CONCLUSION: Cytoreductive nephrectomy is associated with better survival in patients with ccmRCC, including those exposed to targeted therapy, after adjustment for multiple potential confounders.

External beam radiation therapy improves survival in high- and intermediate-risk non-metastatic octogenarian prostate cancer patients.

PURPOSE: There is no contemporary proof of cancer-control benefits in octogenarian clinically localized prostate cancer (PCa) patients with life expectancy (LE) < 10 years. Therefore, cancer-specific mortality (CSM) rates after external beam radiation therapy (EBRT) vs. no local treatment (NLT) were tested in octogenarian PCa patients with LE < 10 years. METHODS: Within the surveillance, epidemiology, and end results database (2004-2015), we identified 22,361 octogenarian clinically localized PCa patients who either received EBRT or NLT. Temporal trends, cumulative incidence plots and multivariable competing-risks regression analyses (MCR) were used after propensity score matching. Sensitivity analyses were performed according to D'Amico risk groups and LE > 5 years. RESULTS: Of all, 7325 (32.8%) received EBRT vs. 15,036 (67.2%) received NLT. Rates of EBRT significantly increased over time (25.0-42.4%). Overall, 10-year CSM rates were 10.6% vs. 17.0% and 10-year other-cause mortality rates were 50.3% vs. 58.1%, in EBRT vs. NLT patients (both p < 0.001). In MCR focusing on the overall cohort, EBRT represented an independent predictor of lower CSM (hazard ratio: 0.5). In sensitivity analyses, hazard ratios of 0.5 (p < 0.001), 0.5 (p < 0.001) and 0.8 (p = 0.5) were, respectively, recorded in D'Amico high-, intermediate- and low-risk patients. In sensitivity analyses addressing patients with LE > 5 years virtually the same results were recorded. CONCLUSIONS: In octogenarian patients with LE < 10 years, EBRT seems to be associated with lower CSM in D'Amico high-risk, as well as in D'Amico intermediate-risk patients relative to their NLT counterparts. Based on these observations, greater consideration for EBRT may be given in octogenarian patients.

Complication rates, failure to rescue and in-hospital mortality after cytoreductive nephrectomy in the older patients.

OBJECTIVES: Historical data showed worse perioperative outcomes after cytoreductive nephrectomy (CN) in older patients. Additionally, the CARMENA trial questioned the survival benefit of cytoreductive CN. We reassessed complication, failure to rescue (FTR) and mortality rates after CN in a contemporary cohort of older patients with metastatic renal cell carcinoma (mRCC). MATERIALS AND METHODS: From National Inpatient Sample (NIS) database (2008-2015), mRCC patients treated with CN were abstracted. Univariable and multivariable logistic regression models tested for the relationship between age (≤55 vs. 56-70 vs ≥71 years), Charlson Comorbidity Index (CCI) and modified Frailty Index (mFI) categories and complications, FTR and in-hospital mortality. All models were clustered, weighted and adjusted for all available patient and hospital characteristics. RESULTS: Of 3644 mRCC patients treated with CN, 924 (25.4%) were ≥ 71 years old, 435 (11.9%) had CCI ≥ 2 and 749 (20.6%) were frail. In multivariable logistic regression models, age ≥ 71 (odds ratio [OR] 1.4, p < .001), CCI ≥ 2 (OR 1.88, p < .001) and frail status (OR 1.91, p < .001) were independent predictors of overall complications. Age ≥ 71 was also an independent predictor of FTR (OR 2.27, p = .04), but not of in-hospital mortality. Both CCI and mFI were not significantly associated with either FTR or in-hospital mortality. CONCLUSION: Older patients with mRCC are more likely to experience higher rates of overall complications, FTR and in-hospital mortality following CN. These results highlight the importance of rigorous selection criteria for older surgical candidates. Moreover, timely recognition and rapid response to complications are particularly critical in this population.

Unmarried men have worse oncologic outcomes after radical cystectomy for nonmetastatic urothelial bladder cancer.

BACKGROUND: Unmarried status is an established risk factor for worse cancer control outcomes and survival in various malignancies. We tested the effect of marital status on the rate of nonorgan confined disease as well as on cancer-specific mortality (CSM) in patients who underwent radical cystectomy for nonmetastatic urothelial bladder cancer (UCUB). METHODS: Within the Surveillance, Epidemiology and End Results database (2007-2015), we identified 11,167 patients (8,639 men and 2,528 women) who underwent radical cystectomy for nonmetastatic UCUB. Temporal trend analyses, logistic regression models, cumulative incidence plots, competing-risks regression models and landmark analyses were used. RESULTS: Overall, 2,454 men (28.4%) and 1,363 women (53.9%) were unmarried. Unmarried men had a higher rate of nonorgan-confined disease at radical cystectomy (OR: 1.24, CI 1.10-1.33; P < 0.001). Moreover, in men, unmarried status was an independent predictor of higher CSM (HR: 1.24, CI 1.12-1.37) In women, unmarried status neither predicted nonorgan-confined disease at radical cystectomy (OR: 1.07, CI 0.91-1.26; P = 0.37) nor was it associated with CSM (HR: 1.13, CI 0.88-1.31; P = 0.14). In 6-month landmark analyses, unmarried status remained an independent predictor of higher CSM in men (HR: 1.20, CI 1.08-1.33). CONCLUSIONS: Unmarried men have more advanced tumor stage at radical cystectomy and worse CSM compared to married men. Interestingly, marital status did not affect oncologic outcomes in women. These data suggest a gender-specific effect of marital status in UCUB.

Unmarried status is a barrier for access to treatment in patients with metastatic renal cell carcinoma.

PURPOSE: We tested the effect of marital status on cytoreductive nephrectomy, metastasectomy, and systemic therapy rates, as well as on cancer-specific mortality (CSM) in patients with metastatic clear cell renal carcinoma (mccRCC). METHODS: Within the Surveillance, Epidemiology and End Results database (2004-2015), we identified 6975 patients (4806 men and 2169 women) with metastatic clear cell renal carcinoma. Temporal trend analyses, logistic regression models, cumulative incidence plots, and competing-risk regression models were used. RESULTS: Overall, 1450 men and 1018 women were unmarried (30.2% and 47.0%, respectively). In men, unmarried status was an independent predictor of lower cytoreductive nephrectomy rate (OR: 0.54), lower metastasectomy rate (OR: 0.70), and lower systemic therapy rate (OR: 0.70). Conversely, in women, unmarried status was an independent predictor of lower cytoreductive nephrectomy rate (OR: 0.63) and of lower systemic therapy rate (OR: 0.80), but not of lower metastasectomy rate (OR: 0.83; p = 0.12). In multivariable competing-risk regression analyses, unmarried status was an independent predictor of higher CSM in men (HR: 1.15), but not in women (HR 0.97, p = 0.6). CONCLUSIONS: Unmarried men are at higher risk of not benefiting of cytoreductive nephrectomy, metastasectomy, or systemic therapy than their married counterparts. Unmarried women are at higher risk of not benefiting of cytoreductive nephrectomy or systemic therapy. These gender-related differences cumulate in higher CSM in unmarried men, but not in unmarried women.