Patient and Hospital Characteristics Associated with Nephron-Sparing Surgery for Small, Localized Kidney Cancers in California,

Transcription

1 Patient and Hospital Characteristics Associated with Nephron-Sparing Surgery for Small, Localized Kidney Cancers in California, Brenda M. Giddings, M.A. California Cancer Reporting and Epidemiologic Surveillance (CalCARES) Program UC Davis Health System, Institute for Population Health Improvement

2 2 Background Kidney cancer incidence has increased in the United States for two decades Increase primarily among small, localized tumors Attributed to incidental detection resulting from widespread use of advanced diagnostic imaging

3 3 Annual Percent Change (APC) in ageadjusted incidence rates for renal cell carcinoma (RCC), California, Period APC P-value < <

4 4 Age-Adjusted Rate / 100, Incidence of RCC by Tumor Size, California, T1a ( <= 4.0 cm) T1b ( cm) T2a ( cm) T2b ( > 10.0 cm) Unknown

5 5 Background 1960s s, complete nephrectomy (CN) was gold standard for treating all renal masses Early 2000s, patients treated with nephronsparing surgery (NSS) had: similar oncologic outcomes enhanced preservation of renal function reduced frequency of cardiovascular events better overall survival compared to patients treated with CN

6 6 Background National Comprehensive Cancer Network Guidelines in Oncology, Kidney Cancer NSS preferred for both T1a and T1b tumors CN should not be employed when NSS can be achieved

7 7 Frequency of CN and NSS for treatment of T1a renal cell cancers, California, Percent % 75% CN % 25% NSS Year

8 8 Study Aims To identify patient, tumor, and hospital characteristics associated with NSS for small, localized kidney cancers in California

9 9 Methods Case Selection (N=10,467) Data Source: California Cancer Registry Criteria: Malignant T1a and T1b kidney tumors Adults aged 20 years and older Treated with nephrectomy Diagnosed and treated, 01/01/ /31/2015

10 10 Methods Identified facility that performed the surgery Examined all reports to identify the facility that performed the most extensive surgery (RX Summ--Surg Prim Site; NAACCR #1290)

11 11 Methods Obtained facility characteristics: Number of staffed beds Teaching or non-teaching Rural or urban Designations American College of Surgeons, Commission on Cancer, cancer program National Cancer Institute designated cancer center National Comprehensive Cancer Network designated cancer center

12 12 Methods Calculated nephrectomy volume for each facility using hospital discharge data Three-year average volume Performed multivariate logistic regression to assess the associations of patient, tumor, and hospital characteristics with NSS

13 Results 13

14 14 Type of nephrectomy for treatment of T1a 2015 Surgery Type Frequency Percent and T1b kidney cancers, California, Nephron- Sparing 6, % Complete Nephrectomy 4, %

15 15 Adjusted Odds Ratio (OR) of NSS Characteristic (referent) OR P-value Age at Dx (20 to 64 years) 65 to 80 years years 0.6 <0.001 Sex (Male) Female Race/Ethnicity (non-hispanic African American white) Hispanic Asian/PI SES (highest quintile) Lowest Low/Middle Middle Middle/High

16 16 Adjusted Odds Ratio (OR) of NSS Characteristic (referent) OR P-value Charlson Comorbidity (0) One or more 0.8 <0.001 Payer (fully insured) Uninsured Dual eligible 0.5 <0.001 Medicaid/County/HIS 0.7 <0.001 Medicare Insured, NOS T value (T1a) T1b 0.2 <0.001 Grade (Grade 1) Grade <0.001 Grade <0.001 Grade <0.001 Nephrectomy Volume Low (<=3/year) 0.5 <0.001 (High, 14+ per year) Medium (4-13/year)

17 17 Adjusted Odds Ratio (OR) of NSS Characteristic (referent) OR P-value NCI Designated (Yes) Not NCI-designated 0.6 <0.001 Facility Location (Urban) Rural 0.2 <0.001 Number of Beds (500+)

18 18 Summary Significant disparities observed Characteristics associated with lowest likelihood of receiving NSS: Tumor-level: large tumors (> 4cm), high grade Patient-level: older (65+ years), female, minority, low income, comorbidities, Medicaid-coverage or dual eligibility Hospital-level: low surgery volume, rural, not NCIdesignated

19 19 Limitations Not all surgeons agree on appropriateness of NSS Cancer registry data No information on location of tumor in kidney No information on patient functional status (although comorbidity score captures some) Insurance information not validated

20 20 Acknowledgements Yi Chen CalCARES Program, Institute for Population Health Improvement, UC Davis Health Cyllene R. Morris, DVM, PhD CalCARES Program, Institute for Population Health Improvement, UC Davis Health Stanley A. Yap, MD, MSc, FRCRC UC Davis Comprehensive Cancer Center Arti Parikh-Patel, PhD, MPH CalCARES Program, Institute for Population Health Improvement, UC Davis Health Kenneth W. Kizer, MD, MPH UC Davis School of Medicine

21 21 Contact Information Brenda M. Giddings