Washington, DC (UroToday.com) Renal cell carcinoma (RCC) is one of the most common types of cancer worldwide, with an estimated 75,000 new cases in 2019. RCC treated with curative intent still results in the development of distant or local recurrences within five years in 20–30% of cases.
At the 20th Annual Meeting of the Society for Urologic Oncology (SUO 2019), during the Kidney Cancer session, Dr. Suzanne Merrill, a Urologic Oncologist from the Penn State Cancer Institute, presented on Optimizing Imaging Surveillance After Treatment for Localized RCC. She began her talk by giving a brief overview of the need for revising the current follow-up imaging guidelines. Cancer follow-up comprises a large portion of the patient visits at the cancer centers, dictating almost 35-40% of the daily patient volume. In today’s healthcare environment, it is also essential to be better stewards of the available medical resources and time. There is increasing oversight by the insurance companies with imaging approvals based on published guidelines, leading to some denials in insurance claims for patients who need more rigorous follow-up.
Dr. Merrill then outlined the current AUA and NCCN guidelines for follow-up surveillance imaging, which is stratified primarily based on the pathologic stage. There are subtle differences between the two guidelines in both the imaging modality and the duration of follow-up recommended. She highlighted her study published in JCO in 2014, which assessed the ability of the available guidelines to capture RCC recurrences, and showed that if strictly followed, the 2014 NCCN and AUA guidelines missed approximately one-third of RCC recurrences. The reasons for missed recurrences were mostly because of risk stratification based only on stage and simple methods for follow-up duration.1 The current AUA and NCCN follow-up schedules fail to account for dynamic changes in risk of recurrence over time, the influence of competing patient comorbidity risk, and RCC recurrences that occur beyond five years.
Dr. Merrill then highlighted additional work that she did to provide an approach to surveillance that balances the risk of recurrence versus the risk of non-RCC death utilizing Weibull modeling. This model provides an individualized approach to RCC surveillance that bases the duration of follow-up on the interplay between competing risk factors of recurrence and non-RCC death. Utilizing a dynamic model may improve the balance between the derived benefit from surveillance and medical resource allocation.2
She also highlighted new models being developed through multi-institutional collaboration, which are based on a similar concept of stratifying risk of recurrence based on histology and stage, and risk of non-RCC death stratified based on age and ECOG. This provides the opportunity to be more selective and may further improve equity and reduce heterogeneity in follow-up care, and ultimately may lead to older or sicker patients receiving less intense follow-up imaging schedule.
Finally, she stressed the importance of separating pT1a from pT1b disease for surveillance imaging, which has been reported by several groups recently. False-positive chest x-rays during follow-up for pT1a disease lead to unnecessary metastatic workup increasing the burden on the healthcare system. In a recent paper published by Dr. Abel and colleagues, for pT3 disease, 1/5th of initial recurrences were outside the recommended imaging template of the chest and abdomen.3 Capturing recurrences when asymptomatic, translated to improved survival, which has been shown in several studies, and therefore it is essential to optimize the resources in favor of patients who will benefit the most. Follow-up visits are vital for the psychological benefit of the patients. In an ongoing prospective survey study of 107 patients with RCC, 78% of the patients reported that follow-up visits conveyed a sense of security, and 88% of patients reported that they would not at all prefer their family physician to do a follow-up.
Dr. Merrill concluded her talk by suggesting that there is a strong rationale to support optimization in follow-up imaging schedule based on alternative risk stratification schemas and new models. There is an urgent need to update the AUA guideline for RCC follow-up, which was last published in 2013 to better align guidelines with the current understanding of RCC and recurrence risk.
Presented by: Suzanne B. Merrill, MD, Assistant Professor, Department of Surgery, Division of Urology, Penn State Cancer Institute, Hershey, Pennsylvania, USA.
Written by: Abhishek Srivastava, MD, Society of Urologic Oncology Fellow, Fox Chase Cancer Center, Fox Chase Cancer Center, Philadelphia, PA, Twitter: @shekabhishek at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC