Association of Surgical Delay and Overall Survival in Patients With T2 Renal Masses
abstract
This abstract is available on the publisher's site.
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To test for an association between surgical delay and overall survival (OS) for patients with T2 renal masses. Many health care systems are balancing resources to manage the current COVID-19 pandemic, which may result in surgical delay for patients with large renal masses.
METHODS
Using Cox proportional hazard models, we analyzed data from the National Cancer Database for patients undergoing extirpative surgery for clinical T2N0M0 renal masses between 2004 and 2015. Study outcomes were to assess for an association between surgical delay with OS and pathologic stage.
RESULTS
We identified 11,848 patients who underwent extirpative surgery for clinical T2 renal masses. Compared with patients undergoing surgery within 2 months of diagnosis, we found worse OS for patients with a surgical delay of 3-4 months (hazard ratio [HR] 1.12, 95% confidence interval [CI] 1.00-1.25) or 5-6 months (HR 1.51, 95% CI 1.19-1.91). Considering only healthy patients with Charlson Comorbidity Index = 0, worse OS was associated with surgical delay of 5-6 months (HR 1.68, 95% CI 1.21-2.34, P= .002) but not 3-4 months (HR 1.08, 95% CI 0.93-1.26, P = 309). Pathologic stage (pT or pN) was not associated with surgical delay.
CONCLUSION
Prolonged surgical delay (5-6 months) for patients with T2 renal tumors appears to have a negative impact on OS while shorter surgical delay (3-4 months) was not associated with worse OS in healthy patients. The data presented in this study may help patients and providers to weigh the risk of surgical delay versus the risk of iatrogenic SARS-CoV-2 exposure during resurgent waves of the COVID-19 pandemic.
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Additional Info
Disclosure statements are available on the authors' profiles:
Association of Surgical Delay and Overall Survival in Patients With T2 Renal Masses: Implications for Critical Clinical Decision-Making During the COVID-19 Pandemic
Urology 2021 Jan 01;147(xx)50-56, KB Ginsburg, GL Curtis, DN Patel, WM Chen, MC Strother, A Kutikov, IH Derweesh, ML CherFrom MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.
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This was a retrospective NCDB analysis of patients undergoing surgery for cT2N0M0 renal masses between 2004 and 2015. A total 11,848 patients who had undergone radical or partial nephrectomy within 6 months of diagnosis with a median follow-up of 41.7 months were included. The primary objective of this study was to test for an association between surgical delay and overall survival. The median renal mass size was 8 cm (interquartile range [IQR], 7–10 cm). The median time from diagnosis to surgery was 4 weeks (IQR, 2–7 weeks) with 10,146 patients (85.6%) undergoing surgery within 2 months, 1453 (12.3%) within 3 to 4 months, and 249 (2.1%) within 5 to 6 months of diagnosis. Compared with patients undergoing surgery within 2 months of diagnosis, there was shorter OS among patients with a surgical delay of 3 to 4 months (HR, 1.12; 95% CI, 1.00–1.25) or 5 to 6 months (HR, 1.51; 95% CI, 1.19–1.91). When considering only healthy patients with CCI of 0, there was shorter OS associated with surgical delay of 5 to 6 months (HR, 1.68, 95% CI, 1.21–2.34; P = .002) but not 3 to 4 months (HR, 1.08; 95% CI, 0.93–1.26; P = .309). The strength of this analysis is that it provides a large sample size to build upon limited data on outcomes with surgical delay, particularly in those with cT2 renal masses. Here, the authors conclude that a delay of surgery of 5 to 6 months may have a worse effect in terms of OS than a shorter surgical delay. This is particularly relevant in the current pandemic whereby medical care has often been delayed. However, it should be noted that patients who experienced a longer surgical delay tended to be older and less healthy in this study and the study results' generalizability to patients who have deferred surgery during the COVID-19 pandemic is unclear. There are also multiple, intrinsic limitations to NCDB retrospective analyses. As such, further investigation is warranted before routine clinical implementation. Providers should continue to rely on consensus and guidelines supported by robust evidence bases for up-to-date COVID-19 pandemic oncologic care recommendations.
At the onset of the COVID-19 pandemic, many institutions were forced to triage the care of patients with little data to guide the triage process or to reassure patients and physicians alike. In this study, data from the National Cancer Database provide sound evidence that surgery for large kidney tumors (cT2, 7 cm or greater) performed within 4 months of diagnosis has minimal impact on oncologic outcomes, including survival, pathologic upstaging, and node-positive disease. At our institution, patients with cT2 renal tumors are typically designated as a priority for surgery (typically within a few weeks). These data support that practice and are reassuring in circumstances where that metric is not achievable.