The report by Kowalczyk et al. provides insight into the contemporary management of the small renal mass . Using the Surveillance Epidemiology and End Results Medicare database, the authors identified 1682 patients who were diagnosed with a small renal mass between 2005 and 2007. Patients were treated with open radical nephrectomy, laparoscopic radical nephrectomy, open partial nephrectomy, laparoscopic partial nephrectomy, ablation or surveillance. Their analysis focused on treatment efficacy, complications, cost and treatment trends. As the authors readily admit, the study design has limitations including short follow-up, selection bias, analysis of administrative data predominantly used for billing purposes, and the fact that all patients were Medicare beneficiaries >65 years of age. Nonetheless, the article does a good job in explaining the population-based trends and outcomes associated with treating the small renal mass.
The authors found that nephron-sparing approaches were associated with significantly fewer postoperative complications when compared with radical nephrectomy. The study also reaffirmed that nephron-sparing surgery significantly reduces the risk of acute renal failure, chronic renal insufficiency, and the need for haemodialysis when compared with radical nephrectomy. Most importantly, the study found that open or minimally invasive nephron-sparing techniques were associated with better cancer-specific survival. The last finding is particularly interesting as it provides an oncological rationale for nephron-sparing surgery, as suggested recently by other reports [2, 3]. Cost of care was another important factor considered in this study. In this regard, the cost of treating the small renal mass was highest when using traditional open surgical techniques (partial and radical nephrectomy) compared with minimally invasive techniques, ablative techniques or active surveillance. There are many ways to look at the cost data. On the one hand, the data may suggest that the most challenging cases are being performed with open techniques. On the other hand they may suggest that the learning curve for minimally invasive approaches has flattened and that results have improved to favourably affect cost.
While the authors make a compelling case for using nephron-sparing surgery to treat the small renal mass, the reality is that there is much more work to do. It is disappointing that radical nephrectomy was the predominant treatment approach for the small renal mass in this study. While a slight decline was observed in the use of laparoscopic radical nephrectomy (34 to 31%) and open radical nephrectomy (29 to 21%) over the study years, this rate of decrease seems unacceptable given the large body of evidence favouring nephron-sparing techniques. Specifically, previous research has also shown that nephron-sparing reduces the risk of cardiovascular, renal and bone-related complications . Indeed, these factors would be especially important in Medicare beneficiaries >65 years old with other comorbidities. Thus, it seems that the concluding statements from years of evidence-based research have largely fallen on deaf ears. Indeed, the latest treatment guidelines published in 2009 suggest that nephron-sparing techniques should be used for the small renal mass when feasible. While the hope would be that new guidelines would favourably influence management strategies, it is also apparent that these ideas were not widely embraced in the current study.
It appears that somewhere during the decision-making process with the patient, evidence-based medicine too often seems to go by the wayside and the decided treatment plan follows a path that seemingly de-emphasizes the patient. For example, on the one hand, it may be easier for the patient to ‘buy in’ to a laparoscopic radical nephrectomy rather than accept a flank incision for a traditional open partial nephrectomy, especially if a referral for minimally invasive partial nephrectomy is not suggested. On the other hand, it may be easier for a patient to accept a quick open radical nephrectomy rather than accept the relatively low risk of urine leak associated with open or minimally invasive partial nephrectomy. With evidence-based medicine and clinical guidelines apparently not doing the trick to rapidly change practice patterns, what is the next step towards increasing nephron-sparing surgery for the small renal mass? While the root cause of lower than expected nephron-sparing surgery for the small renal mass is probably multifactorial, third party payers and healthcare reform may ultimately influence therapeutic trends. From a cost standpoint, third party payers want treatments that are efficacious and also associated with low cost. Our patients, increasingly paying more for their healthcare, also want the same thing. While there is fear that healthcare reform could erode the patient-physician relationship, one positive patient benefit might be that care is mandated in an evidence-based fashion with an emphasis on overall cost, oncological efficacy and overall risk of complications.