uRoloGIC onColoGy - University of Michigan Health System

The CurrenT STaTe of urologiC onCology | iSSue 1 | winTer 2012
rising incidence rates of renal cell carcinoma:
challenges for the 21st century
David Miller, MD
Assistant Professor of Urology Surgery
national incidence rates for renal cell carcinoma
(rcc) have risen steadily during the past
two decades. this trend is mediated mainly
by an increase in the number of patients with
early-stage cancers. During this time period,
the treatment paradigm for solid renal masses
has favored their expedient removal upon
detection. consequently, an increase in the
frequency of kidney cancer surgery has paralleled
the rising incidence of rcc. Although
it is not endorsed universally, the current
treatment paradigm is based on the assumption
that early intervention (i.e., treatment of
patients presumed to have early, low-stage
disease) will result in better survival outcomes.
in many ways, the rising incidence of renal
cell carcinoma, and the concurrent increase in
surgical therapy, provides a useful framework
for considering the major challenges and
opportunities for improving care and outcomes
for patient with renal cell carcinoma
in the 21st century. first, there is still a need
to continue improving surgical patterns of
care among patients with early-stage rcc.
open radical nephrectomy has long been the
standard treatment for this group of patients.
in recent years, however, easier convalescence
and equivalent cancer control established
laparoscopy as an alternative standard of care
for most patients treated with radical nephrectomy.
concurrent with the gradual dissemination
of laparoscopic radical nephrectomy,
studies have demonstrated that for patients
with small rccs (i.e., generally those ≤ 4
cm), partial instead of radical nephrectomy
achieves identical cancer control while better
preserving long-term renal function and
reducing overtreatment of benign or clinically
indolent tumors.
from a clinical perspective, therefore, it can
be argued that the benefits of partial nephrectomy
and laparoscopy support the application
of one or both of these techniques for a
vast majority of patients with organ-confined
rccs. However, recent studies suggest that
6
open radical nephrectomy remains an all-toocommon
surgical treatment for many patients
with early-stage rcc. Among the many factors
that may be impeding the adoption of
laparoscopy and/or partial nephrectomy are
the technical complexity of these procedures,
and a lingering absence of professional consensus
regarding optimal surgical therapy for
patients with small rccs. in light of these
concerns, several mentored- and simulatorbased
types of training have now emerged to
facilitate the development and transfer of minimally
invasive surgical techniques, including
both robotics and standard laparoscopy. in
order to complement these efforts, members
of the urology community now also have a
clear opportunity (and arguably strong motivation)
to support additional research and/or
development of clinical guidelines that clarify
optimal treatment algorithms for patients with
kidney cancer. the recently released AUA
guidelines for management of patients with
small renal masses represent an important
step forward in this area.
in many ways, the rising incidence of renal
cell carcinoma, and the concurrent increase in
surgical therapy, provides a useful framework
for considering the major challenges and
opportunities for improving care and outcomes
for patient with renal cell carcinoma
in the 21st century.
A second, and related, challenge stems from
the biological heterogeneity of rcc and
the physiological heterogeneity of patients
presenting with these tumors. in particular,
the growing recognition that a non-trivial
proportion of rccs may have an indolent
clinical course, and that many patients with
these tumors ultimately die from other causes,
has heightened interest in the expansion of
active surveillance as an initial management
strategy for patients with early-stage kidney
cancer. the potential merits and pitfalls of
this approach, including the potentially pivotal
role of percutaneous renal mass biopsy
for patient selection, are discussed in a separate
section of this newsletter. moreover, the
evidence base and rationale for active surveillance
would also be enhanced greatly by a
better understanding of the implications of
co-morbid disease among patients with kidney
cancer. in fact, at least one recent study suggests
that nearly 25 percent of patients with
rcc have at least two significant comorbidities
at the time of their cancer diagnosis.
Given this, an important 21st-century challenge
for urologists is to better define longterm
survival outcomes among patients with
rcc, including the frequency of deaths due
to causes unrelated to the cancer diagnosis.
these data, when combined with detailed
information on the duration and severity of
comorbid conditions, may prove invaluable
to understanding and predicting competing
causes of death among patients considering
surgical treatment for
kidney cancer. this
information will, in
turn, inform ongoing
debates surrounding
the appropriate treatment
intensity (versus
expectant approaches)
for populations of
patients with earlystage
rcc.
in summary, the
incidence of rcc continues to rise in the 21st
century. As the physicians responsible for the
treatment of a majority of patients with this
common malignancy, we in the urology community
have a tremendous opportunity to
work together to continually refine and optimize
the surgical and non-surgical treatment
of patients with renal cell carcinoma. i look
forward to joining you in this effort.