THE CASE FOR PARTIAL NEPHRECTOMY: ACTION IS REQUIRED

Authors


Maxine Sun, Cancer Prognostics and Health Outcomes Unit, University of Montreal Health Center, 1058 rue St-Denis, Montreal, QC, Canada H2X 3J4. e-mail: maxine@purplar.com

Abbreviation
(P)(R)N

(partial) (radical) nephrectomy

INTRODUCTION

Small renal masses represent >60% of all newly diagnosed RCC cases and have been the driving force behind the tremendous rise in incidence of kidney cancer over the last two decades [1]. Whereas surgical excision remains the standard-of-care treatment when there is curative intent, the debate on the type of nephrectomy (partial nephrectomy [PN] vs radical nephrectomy [RN]) persists. On this matter, comparative effectiveness between the two approaches has been elaborately examined, and re-examined. Whether it be using institutional [2] or retrospective observational databases [3,4], relying on propensity-based matched [3] or instrumental variable approaches [5], focusing on overall survival [4,5], other-cause mortality [3], or even renal function- [2,6] and cardiovascular-related endpoints [4], most of which agree and corroborate the benefits of PN in patients with early-stage kidney cancer.

In the April 18, 2012 issue of JAMA, Tan et al.[5] re-assess the efficacy of PN vs RN, with respect to long-term survival. To simulate randomisation and reduce treatment-related biases, authors relied on the instrumental variable approach. Reiterating previous studies' findings [2–4,6], the authors found that treatment with a PN rather than a RN is associated with a statistically significant and clinically relevant improvement in survival among Medicare surgical candidates.

In light of an abundant concordant literature supporting the use of PN in patients with small renal masses, the ultimate question remains as to whether all such clinical research can dissuade providers from offering RN when PN is feasible. In an attempt to appraise whether such culminating clinical research had an impact on physicians' decision to opt for a nephron-sparing approach, we previously examined the use of PN in the community setting using contemporary data. Unfortunately, as recently as 2008, RN remains the predominant surgical treatment for localised RCC (T1a) [7]. The disconnect between evidence-based findings and actual clinical practice is unclear, given that to date, there is clearly not a lack of high-quality well-conceptualised articles assessing the comparison. However, it may be that the merits of such articles are well-received by physicians who routinely perform PN, and that surgeons who perform RN, or who do not have the technique to do otherwise are left indifferent at such publications.

The benefit of PN over RN in comparative effectiveness is not novel research, but remains poorly implemented in real clinical practice. Under these circumstances, the perseverance of investigators such as Tan et al.[5] to pursue this topic in clinical research should be applauded. The lack of widespread adoption of a treatment that has shown superior comparative effectiveness relative to another in terms of clinical outcomes may be regarded as a waste of resources and spending. Given the current state of healthcare, there is little room for misuse and underuse. Regardless of whether the paradigm shift needs to be initiated by the patient, the payer and/or the government, the fact remains that there is an urgent need to incorporate these findings into contemporary clinical practice.

CONFLICTS OF INTEREST

None declared.

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