The role of surgery in kidney cancer is evolving as new advancements continue to be made. Now oncologists, surgeons and patients must make decisions about active surveillance and renal biopsy, as well as the benefits of partial versus radical nephrectomy.
In an interview with CURE, Alexander Kutikov, an attending surgeon and associate professor of Urologic Oncology at Fox Chase Cancer Center, discusses these issues and the shifting role of surgery in kidney cancer.
What is the current role for surgery in resectable kidney cancer?
Kidney cancer remains an incredibly surgical disease — a chance to operate on a patient is really a chance to cure them. However, although we are doing more surgery, some data have shown that mortality rates are still rising.
Our group at Fox Chase Cancer Center, partnered with the University of Michigan, is working to show that the treatment-disconnect phenomenon between mortality and surgery rate is not as profound as we previously thought.
If you control for missing data and increasing incidence, you can actually show that the effect is quite attenuated. Most of us believe that we are actually moving the needle to help stop the progression of kidney cancer in cases that are localized.
What factors must be considered when determining if a patient should or should not undergo surgery?
When one faces a localized kidney cancer, there are several factors to consider. Should you do the surgery? When should you do the surgery? What kind of surgery is needed — partial or radical? What technique should be used? What treatment should be done after the surgery?
Most of us believe that tumors that are less than three centimeters that show zero-order or really sluggish growth kinetics are good candidates for active surveillance. This is especially important in older patients or those with comorbidities.
With regard to taking a patient to surgery, our group has really pushed the idea of not making that decision in a vacuum. You need to integrate competing risks of death into that decision-making. We have published tools to quantitate that decision and give oncologists jumping-off points to contextualize that to the patient.
What role does biopsy play in the decision to perform or not perform surgery?
The use of renal biopsy is really gaining traction in the clinical cancer space. In many cases, that can help one decide whether to do surgery or not — especially in elderly or frail patients. Renal biopsy is terrific at separating the sharks from the minnows. It allows us to determine if there is a benign mass. For a patient who is at increased risk if they were to receive surgery, doing a biopsy and finding a benign mass is incredibly actionable and helpful. More and more biopsies are being done.
What renal biopsy is not great at is distinguishing between low- and high-grade tumors. It cannot tell those apart. There are a lot of people in this space who are working to improve that.
There is a big debate in the field on whether one should biopsy to all comers, but we are not quite there yet. In elderly patients who are candidates for active surveillance, I am not sure a biopsy is helpful. Also, data with regard to follow-up of benign masses are just not robust enough for me to not treat a young, healthy patient with a benign mass and follow them long-term.
Once surgery is determined to be the best course of action for the patient, what other considerations must be made?
We need to decide whether or not we do a partial or radical nephrectomy and to appropriately present the data to the patient. There is no question that, for masses that are less than four centimeters and are anatomically simple, a partial nephrectomy is the standard of care.
The question comes up if it’s a bigger and more anatomically complex mass, especially in a patient with a normal contralateral kidney. In this case, do we do a partial or radical nephrectomy? We know that a partial nephrectomy is associated with higher risk, and those risks are perioperative and are almost double.
Many of us think the oncologic safety of partial nephrectomy for larger masses does not have robust enough data. It is a really a clinical struggle with these patients to know what to do. Obviously, our enthusiasm for partial nephrectomy is fueled by retrospective data sets that show us that there is potentially an overall survival benefit to partial nephrectomy. In this sort of environment where there is a lot of uncertainty, we know that there is a little bit higher risk for a complex partial nephrectomy, and we have to weigh that against the potential benefits. The time is really ripe for a randomized trial.