NCCN AND AUA GUIDELINES FOR RCC:

Transcription

1 NCCN AND AUA GUIDELINES FOR RCC: DO THEY EFFECTIVELY CAPTURE RECURRENCES FOLLOWING NEPHRECTOMY? Suzanne B. Stewart, MD 1, R. Houston Thompson, MD 1, Sarah P. Psutka, MD 1, John C. Cheville, MD 2, Christine M. Lohse 3, Stephen A. Boorjian, MD 1, Bradley C. Leibovich, MD 1 1 Department of Urology, 2 Department of Pathology, 3 Department of Health Sciences Research Mayo Clinic, Rochester, MN 2013 MFMER slide-1

2 Background Multiple protocols exist for the oncologic surveillance of RCC NCCN and AUA guidelines are highly recognized Protocols are disparate No definitive evidence to clarify which is the most efficacious 1,2 As a result Significant heterogeneity in surveillance care 3 Over and underutilization of testing for certain patient groups 1 Skolarikos A et al. Eur Urol. 2007; 2 Chin AI et al. Rev Urol. 2006; 3 Feuerstein MA et al. SUO MFMER slide-2

3 Objectives 1. Evaluate the performance of the NCCN and AUA guidelines How many RCC recurrences are detected when abiding by prescribed protocols 2. Summarize the total duration of surveillance required to capture 90%, 95% and 100% of RCC recurrences 2013 MFMER slide-3

4 Guideline Protocol NCCN (2013) all patients 6 months for abdominal/chest sites 5yrs for bone/other sites AUA stratified by stage and surgical approach LR-partial (pt1n0): 3yrs for all sites LR-radical (pt1n0): 1yr for abdominal and 3yrs for chest/bone/other sites M/HR (>pt2 or N+): 5yrs for all sites 2013 MFMER slide-4

5 Methods Retrospective review of Mayo Clinic Renal Tumor Registry between N = 3, 803 M0 RCC radical/partial nephrectomy Median postoperative follow-up 9yrs (IQR 5.7, 14.4) Mayo surveillance strategy: Exam, chest/abdominal imaging, labs: 3-6 months x 3yrs 6-12 months x 2yrs annually 2013 MFMER slide-5

6 Methods Disease recurrence = local recurrence or metastasis on imaging or by biopsy > 30d from surgery Only first recurrence counted as an event 1088 (29.8%) developed recurrence Median time to recurrence 1.9yrs (IQR 0.6, 5.5; range 0.1, 38) Patients were stratified according to: Recurrence location: abdomen, chest, bone and other 2013 MFMER slide-6

7 Number of recurrences captured by the NCCN and AUA prescribed surveillance periods Number of recurrences captured (%) By AUA Risk Group By Recurrence Location Guideline NCCN AUA Total N = (35.9) 728 (66.9) LRpartial N = (12.8) 35 (37.2) LRradical N = (24.2) 56 (29.5) M/HR N = (41.3) 637 (79.3) Abdomen N = (19.2) 256 (58.6) Chest N = (29.0) 324 (73.3) Bone N = (80.1) 127 (76.5) Other N = (67.1) 99 (62.6) Approximately 2/3 rd and 1/3 rd of recurrences were missed by NCCN and AUA Most restrictive for low risk patients and capturing abdominal relapses 2013 MFMER slide-7

8 2013 vs 2014 NCCN Guidelines 2013 NCCN all patients 6 months for abdominal/chest sites 5yrs for bone/other sites 2014 NCCN stratified by stage and surgical approach pt1nx/0: 3yrs for chest and 5 yrs bone/other sites partial Nx: 3yrs for abdomen radical Nx: 1yr for abdomen pt2-3nx/0 or pt1-3n1: 5yrs for all sites pt4nx-1: Indefinite 2013 MFMER slide-8

9 Table 1. Number of recurrences captured by the 2013 and 2014 NCCN and AUA prescribed surveillance periods Number of recurrences captured (%) By AUA Risk Group By Recurrence Location Guideline 2013 NCCN 2014 NCCN AUA Total N = (35.9) 742 (68.2) 728 (66.9) LRpartial N = (12.8) 36 (38.3) 35 (37.2) LRradical N = (24.2) 67 (35.3) 56 (29.5) M/HR N = (41.3) 639 (79.5) 637 (79.3) Abdomen N = (19.2) 258 (59.0) 256 (58.6) Chest N = (29.0) 326 (73.8) 324 (73.3) Bone N = (80.1) 134 (80.7) 127 (76.5) Other N = (67.1) 106 (67.1) 99 (62.6) 2013 MFMER slide-9

10 Figure 1. Total duration of surveillance to capture 90%, 95%, and 100% of recurrences A longer duration of surveillance appears necessary Caption: *Estimated duration of surveillance due to the few recurrences in these groups MFMER slide-10

11 Limitations Retrospective design Mayo Clinic follow-up was not standardized < 3% were lost to follow-up No strong evidence that surveillance survival benefit Despite this unknown, surveillance continues to remain an integral part of RCC care 2013 MFMER slide-11

12 Conclusions First large scale study to evaluate NCCN and AUA guidelines for RCC Do not comprehensively capture recurrences Approximately 2/3 rd (2013 NCCN) and 1/3 rd (AUA and 2014 NCCN) of all recurrences are missed A longer duration of follow-up appears necessary 2013 MFMER slide-12

13 Thank You 2013 MFMER slide-13