Initial cytoreductive nephrectomy prolongs OS in metastatic renal cell carcinoma
Initial cytoreductive nephrectomy (CN) provides overall survival (OS) advantage in metastatic renal cell carcinoma (mRCC) compared with initial systemic therapy, a recent study reports.
Drawing data from the Surveillance, Epidemiology and End Results registries, researchers looked at 537 elderly patients (>65 years of age) with mRCC. They conducted sequential survival analysis to evaluate the effect of initial CN on OS, as well as instrumental variable analysis to account for measured and unmeasured selection bias.
Of the patients, 190 underwent initial CN followed by targeted therapy and 347 received initial targeted therapy.
Median OS was 17.4 months (IQR, 9.8 to 32.0) in the initial CN group compared with 9.2 months (IQR 4.3 to 18.0) in the initial targeted therapy group. On Cox proportional hazards analysis, initial CN improved OS by 50 percent (95 percent CI, 0.38 to 0.65). Propensity score matching showed that initial CN was associated with a survival advantage of 5.8 months (1.9 to 9.7).
In an analysis accounting for confounding, only a trend toward improved survival with initial CN (hazard ratio, 0.29; 0.08 to 1.00) was observed.
The improved OS observed with initial CN notwithstanding, researchers noted that selection for CN in the contemporary mRCC era might be confounded by regional variation and influenced by provider uncertainty. They highlighted the need for prospective randomized controlled trials to definitively address this clinical conundrum.
Current consensus-based guidelines recommend CN in carefully selected mRCC patients with a disease that can be managed with surgical resection. This is based on high-level evidence of CN with cytokine therapy and supported by retrospective cohort studies of CN with contemporary therapies. [Eur Urol 2015;67:913-924; J Natl Compr Canc Netw 2015;13:151-159]