RAPID DISEASE PROGRESSION IS THE PRIMARY REASON PATIENTS FAIL TO RECEIVE SYSTEMIC THERAPY FOLLOWING CYTOREDUCTIVE NEPHRECTOMY (CN)

Abstract

INTRODUCTION AND OBJECTIVES: Prospective randomized trials have demonstrated a survival benefit to CN in patients with metastatic renal cell carcinoma (mRCC) treated with immunotherapy. These data have been extrapolated to support CN in the targeted therapy era as well. Nevertheless, the likelihood that patients undergoing CN will receive systemic treatment postoperatively remains poorly defined. We evaluated the utilization of systemic therapy at a tertiary referral center in patients undergoing CN. METHODS: 119 patients undergoing CN between 19902008 were identified from our institutional kidney cancer registry. Data regarding systemic therapy were available for 95 patients and form the basis of this analysis. Logistic and Cox regressions were used to evaluate the impact of perioperative variables on patients’ receipt of systemic therapy and survival. RESULTS: Median age at CN was 62 years (range 35-82). 68 patients (72%) received some form of postoperative systemic therapy, at a median of 3 months (range 0.1-62) after CN. In this group, 49% (33/68) were treated with immunotherapy, 37% (25/68) received targeted agents, and 15% (10/68) received other regimens. Patients who did not receive systemic therapy failed to do so because of rapid postoperative progression of disease (37%, 10/27), decision by medical oncology for surveillance (22%, 6/27), patient refusal (15%, 4/27), perioperative death (15%, 4/27), and unknown reasons (11%, 3/27). Receipt of systemic therapy was associated with younger age (p=0.015), but not with performance status (PS) (p=0.30), year of CN (p=0.94), perioperative complications (p=0.19), histological tumor subtype (p=0.74), or number of metastases (p=0.82). At a median postoperative follow-up of 17 months (range 0.27-120), 72 patients (76%) had died, at an estimated median of 23 months following CN. Longer length of stay (HR=1.15; 95% CI 1.06-1.25; p=0.001), poor PS (HR=1.58, 95% CI 1.04-2.42, p=0.03), and sarcomatoid histology (HR=3.34, 95% CI 1.73-6.44, p<0.001) were associated with shorter time to death, while resection of metastases correlated with a decreased risk of mortality (HR=0.37, 95% CI=0.190.74; p=0.005). CONCLUSIONS: Nearly 1/3 of patients undergoing CN never received postoperative systemic treatment. The most common reason patients failed to receive medical therapy was rapid progression of disease. Additional studies are needed to identify those patients at highest risk for progression who might benefit from a neoadjuvant treatment approach.