Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines

Suzanne Merrill, R. Houston Thompson, Sarah P. Psutka, John C. Cheville, Christine M. Lohse, Stephen A. Boorjian, Bradley C. Leibovich

Research output: Contribution to journalArticle

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Abstract

Purpose: The National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). Herein, we assess the ability of the guidelines to capture RCC recurrences and determine the duration of surveillance required to capture 90%, 95%, and 100% of recurrences. Patients and Methods: We evaluated 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared. Results: At a median follow-up of 9.0 years (interquartile range, 5.7 to 14.4 years), a total of 1,088 patients (29.8%) experienced a recurrence. Of these, 390 recurrences (35.9%) were detected using 2013 NCCN recommendations, 742 recurrences (68.2%) were detected using 2014 NCCN recommendations, and 728 recurrences (66.9%) were detected using AUA recommendations. All protocols missed the greatest amount of recurrences in the abdomen and among pT1Nx-0 patients. To capture 95% of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were $1,228.79 using 2013 NCCN, $2,131.52 using 2014 NCCN, and $1,738.31 using AUA guidelines. However, if 95% of LR-partial recurrences were captured, costs would total $9,856.82. Conclusion: If strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.

Original languageEnglish (US)
Pages (from-to)4059-4065
Number of pages7
JournalJournal of Clinical Oncology
Volume32
Issue number36
DOIs
StatePublished - Dec 20 2014

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Renal Cell Carcinoma
Guidelines
Recurrence
Neoplasms
Medicare
Nephrectomy
Costs and Cost Analysis
Health Care Costs
Abdomen
Patient Care

All Science Journal Classification (ASJC) codes

  • Oncology
  • Cancer Research

Cite this

Merrill, Suzanne ; Thompson, R. Houston ; Psutka, Sarah P. ; Cheville, John C. ; Lohse, Christine M. ; Boorjian, Stephen A. ; Leibovich, Bradley C. / Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines. In: Journal of Clinical Oncology. 2014 ; Vol. 32, No. 36. pp. 4059-4065.
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abstract = "Purpose: The National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). Herein, we assess the ability of the guidelines to capture RCC recurrences and determine the duration of surveillance required to capture 90{\%}, 95{\%}, and 100{\%} of recurrences. Patients and Methods: We evaluated 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared. Results: At a median follow-up of 9.0 years (interquartile range, 5.7 to 14.4 years), a total of 1,088 patients (29.8{\%}) experienced a recurrence. Of these, 390 recurrences (35.9{\%}) were detected using 2013 NCCN recommendations, 742 recurrences (68.2{\%}) were detected using 2014 NCCN recommendations, and 728 recurrences (66.9{\%}) were detected using AUA recommendations. All protocols missed the greatest amount of recurrences in the abdomen and among pT1Nx-0 patients. To capture 95{\%} of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were $1,228.79 using 2013 NCCN, $2,131.52 using 2014 NCCN, and $1,738.31 using AUA guidelines. However, if 95{\%} of LR-partial recurrences were captured, costs would total $9,856.82. Conclusion: If strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.",
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Evaluation of the National Comprehensive Cancer Network and American Urological Association renal cell carcinoma surveillance guidelines. / Merrill, Suzanne; Thompson, R. Houston; Psutka, Sarah P.; Cheville, John C.; Lohse, Christine M.; Boorjian, Stephen A.; Leibovich, Bradley C.

In: Journal of Clinical Oncology, Vol. 32, No. 36, 20.12.2014, p. 4059-4065.

Research output: Contribution to journalArticle

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AU - Merrill, Suzanne

AU - Thompson, R. Houston

AU - Psutka, Sarah P.

AU - Cheville, John C.

AU - Lohse, Christine M.

AU - Boorjian, Stephen A.

AU - Leibovich, Bradley C.

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N2 - Purpose: The National Comprehensive Cancer Network (NCCN) and American Urological Association (AUA) provide guidelines for surveillance after surgery for renal cell carcinoma (RCC). Herein, we assess the ability of the guidelines to capture RCC recurrences and determine the duration of surveillance required to capture 90%, 95%, and 100% of recurrences. Patients and Methods: We evaluated 3,651 patients who underwent surgery for M0 RCC between 1970 and 2008. Patients were stratified as AUA low risk (pT1Nx-0) after partial (LR-partial) or radical nephrectomy (LR-radical) or as moderate/high risk (M/HR; pT2-4Nx-0/pTanyN1). Guidelines were assessed by calculating the percentage of recurrences detected when following the 2013 and 2014 NCCN and AUA recommendations, and associated Medicare costs were compared. Results: At a median follow-up of 9.0 years (interquartile range, 5.7 to 14.4 years), a total of 1,088 patients (29.8%) experienced a recurrence. Of these, 390 recurrences (35.9%) were detected using 2013 NCCN recommendations, 742 recurrences (68.2%) were detected using 2014 NCCN recommendations, and 728 recurrences (66.9%) were detected using AUA recommendations. All protocols missed the greatest amount of recurrences in the abdomen and among pT1Nx-0 patients. To capture 95% of recurrences, surveillance was required for 15 years for LR-partial, 21 years for LR-radical, and 14 years for M/HR patients. Medicare surveillance costs for one LR-partial patient were $1,228.79 using 2013 NCCN, $2,131.52 using 2014 NCCN, and $1,738.31 using AUA guidelines. However, if 95% of LR-partial recurrences were captured, costs would total $9,856.82. Conclusion: If strictly followed, the 2014 NCCN and AUA guidelines will miss approximately one third of RCC recurrences. Improved surveillance algorithms, which balance patient benefits and health care costs, are needed.

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