Renal Cell Cancer: A Shift in Approaches for Treatment of Advanced Disease in the United States

Several new agents have become available to treat renal cell cancer (RCC) in recent years, although evidence on their dissemination is limited. This study examined recent trends in RCC treatment in US community practices. Data from the population-based National Cancer Institute’s Patterns of Care studies were used to evaluate treatment of patients with RCC newly diagnosed in 2004 and 2009 (N=2357). Descriptive statistics and logistic and Cox proportional hazards regression analyses were used to assess treatment patterns and the associations among demographic, clinical, and hospital characteristics, with receipt of systemic therapy and time-to-systemic treatment. Between 2004 and 2009, systemic therapy use increased among patients with stage III and IV RCC, from 3.8% to 15.7% and 35.2% to 57.4%, respectively. Among patients with stage IV disease, the most commonly used therapies changed from interleukin-2 (16.3%) and interferon-alfa (16.6%) in 2004 to sunitinib (39.2%) and temsirolimus (15.2%) in 2009. Further, notable decreases were seen in the use of surgery and time-to-systemic treatment for patients with stage IV disease. Patients who were older, living in areas with lower educational attainment, and diagnosed in 2004 were significantly less likely to receive systemic therapy and had longer time-to-systemic treatment (P<.05). The findings indicate that over the past decade, treatment for RCC in the United States has evolved toward increased use of systemic therapy. As the diffusion of new therapies continues, it will be imperative to understand how variation in care for RCC will impact health outcomes and costs of care.

In 2013, approximately 65,150 individuals in the United States were diagnosed with renal cell cancer (RCC).1 Most (>60%) will have localized disease at diagnosis, although recurrences will develop in approximately 40% of patients initially treated for localized disease, and nearly 30% will be diagnosed with metastatic disease.2

While surgery remains the primary treatment for localized RCC,3 treatment options for metastatic RCC have changed markedly in the past decade. Before 2005, interferon alfa (IFN-α) and interleukin (IL)-2 comprised the available systemic treatment options. Since then, 7 new agents have been approved by the FDA for treatment of RCC: sorafenib, sunitinib, temsirolimus, bevacizumab, everolimus, pazopanib, and axitinib.4,5 In view of these developments, the current analysis of RCC treatment was conducted, building on a previous study in adults diagnosed with RCC.6 Using a population-based sample of patients in the United States, the trends in treatment of RCC in community practice were examined, focusing on systemic therapy.

Patients and Methods

Data Source and Study Sample

NCI Patterns of Care Data: The NCI SEER program collects information on all cancer diagnoses in defined geographic regions. Currently, SEER covers approximately 28% of the US population.7 Information for each patient in SEER is primarily obtained from hospital records and includes tumor characteristics, treatment, and select demographic characteristics. Given that systemic therapies are primarily provided in out-patient settings, these data are underreported in SEER. To obtain therapy information that is not well-collected by routine SEER activities, NCI annually conducts Patterns of Care/Quality of Care studies on select cancer sites. Each SEER registry obtains approval, as necessary, from their Institutional Review Board before study initiation.

After undergoing training, abstractors from the 14 participating SEER registries (the metropolitan areas of San Francisco/Oakland, Detroit, Seattle, Atlanta, San Jose/Monterey, and Los Angeles County; the states of Connecticut, Iowa, Kentucky, Louisiana, New Jersey, New Mexico, and Utah; and the remainder of California) reabstracted the hospital records of sample patients to verify tumor characteristics and demographic information. Each patient’s physician was asked to verify treatments with radiation, chemotherapy, or immunotherapy; use of novel agents; and whether the patient participated in a clinical trial. For quality control purposes, 5% of patients had their records reabstracted.

Sample: The study sample included 2357 patients diagnosed with RCC (International Classification of Diseases, Oncology, 3rd revision [ICD-O-3] site code C64.9 and histology codes M-9590 to M-99989) in 2004 and 2009. Patients previously diagnosed with another cancer, diagnosed only at autopsy or on death certificate, or who were younger than 20 years were ineligible for the study. Eligible patients were stratified by registry, sex, race/ethnicity, and disease stage (2009 only), and randomly sampled within strata. Women, non-Hispanic blacks, Asian/Pacific Islanders, Hispanics, American Indians, and Alaskan natives were oversampled to obtain more stable estimates for these groups. In 2009, patients with stage IV disease were oversampled. Sampling fractions were used to calculate weighted percentages that reflect the SEER populations from which the data were obtained.

Measures and Statistical Analyses

Patient characteristics included age at diagnosis, sex, race/ethnicity, marital status, insurance status, geographic region, and Census tract median household income and percent of individuals with less than a high school education. Clinical information included AJCC 6th edition tumor stage, tumor size, number of lymph nodes examined, number of positive lymph nodes, cell type, histologic grade, Charlson comorbidity score, primary site surgery, therapeutic agents, and clinical trial participation. Hospital characteristics included number of beds, ownership type, and residency training program.

Time-to-systemic treatment was defined as the number of days between (1) diagnosis and systemic therapy, for patients who did not receive cancer-directed surgery, and (2) surgery and systemic therapy, for patients who underwent surgery before receiving systemic therapy. Censoring events included date of last follow-up, date of death, or December 31, 2005 and December 31, 2010 (study cutoff dates for patients diagnosed in 2004 and 2009, respectively). Because SEER registries collect month and year of diagnosis, but not the day of diagnosis, the authors assumed that all patients were diagnosed on the first day of the month. The authors also assumed that all patients were followed through the last day of the month and, for all other events (date of surgery, date of systemic therapy), patients for whom data on the day of the event were missing, they assumed that patients experienced the event on the last day of the month (n=72). Cancer-directed surgery (eg, radical nephrectomy, complete/total/simple nephrectomy, partial/subtotal nephrectomy, or kidney resection with other organ resection) before systemic treatment, among patients who received systemic therapy, was categorized into a binary variable.

Statistical Analyses: All descriptive information is presented as the total counts and weighted percentages. Patient, clinical, and hospital characteristics were compared, by year of diagnosis, using Pearson’s chi-square test.

Evaluation of systemic therapy was conducted to assess the proportion of patients who received therapy within 12 months after diagnosis. Regression analysis was limited to patients with stage IV disease, for whom the NCCN Clinical Practice Guidelines in Oncology for Kidney Cancer recommend systemic therapy (to view the most recent version of these guidelines, visit NCCN.org).8 Among patients with stage IV disease who received systemic therapy, the authors measured (1) the type of systemic agent received and (2) the proportion of patients who received any surgery before systemic therapy treatment. Pearson’s chi-square test was used to estimate differences between outcomes by year of diagnosis. In addition, logistic regression was used to evaluate the association between year of diagnosis and patient, clinical, and hospital characteristics and receipt of any systemic therapy within 12 months.

For time-to-systemic treatment analyses, Kaplan-Meier graphs were generated and Cox proportional hazards regression was used to assess the association between year of diagnosis and patient, clinical, and hospital characteristics and time-to-systemic treatment. The log-rank test was performed to test the equality of Kaplan-Meier failure curves by year of diagnosis. For the Cox regression analysis, a lower hazard ratio (HR; <1.0) reflects longer time to receipt of systemic therapy. Patients with missing information on month or year of systemic therapy were excluded from the time-to-treatment analysis only (n=84). Because the evaluation of time-to-systemic treatment reflects any changes in patterns of surgery between 2004 and 2009, sensitivity analyses were also conducted, wherein the authors stratified the time-to-systemic treatment analysis for patients who received surgery within 12 months postdiagnosis (n=290) and those did not receive surgery (n=348).

Patient, clinical, and hospital characteristics with a statistically significant association with the dependent variable at a P value less than .20 in bivariate analyses were retained in the multivariate regression models. Because of collinearity between Census tract estimates of median household income and percent of individuals with less than a high school education (correlation coefficient, 0.76), and a nonsignificant difference in median household income by year of diagnosis, the authors excluded income from the multivariate models. Charlson comorbidity score and SEER registry were included in all multivariate models. All tests of significance were 2-sided. Stata/SE 11.0 (StataCorp LP, College Station, TX) statistical software was used to incorporate sample weights in all analyses.

Results

Most patients, in both study years, were aged 50 to 69 years, married, had private insurance, and a Charlson comorbidity score of zero (Table 1); however, compared with patients diagnosed in 2004, a significantly lower proportion of patients in 2009 were female, non-Hispanic white, and resided in an area with higher educational attainment (P<.05). Further, although patients with stage IV disease were oversampled in 2009, the weighted distribution of disease stage differed significantly between study years (P<.01) because patients diagnosed in 2009 had a greater proportion of stage I (61.1%) and stage IV (15.3%) RCC compared with 56.4% and 14.4%, respectively, in 2004.

From 2004 to 2009, there were substantial changes in the patterns of systemic therapy use among patients with stage III and IV RCC, with receipt of any systemic therapy in the first 12 months after diagnosis increasing from 3.8% to 15.7% among patients with stage III RCC (P<.01) and 35.2% to 57.4% among patients with stage IV RCC (P=.02; Figure 1). Among patients with stage IV disease who received systemic therapy within the first 12 months, a significantly smaller proportion of those diagnosed in 2009 received surgery before systemic therapy (49.7%) compared with patients diagnosed in 2004 (74.8%; P<.01; data not shown). Approximately 83% (n=40) of patients with stage III disease underwent surgery before receipt of systemic therapy, among whom nearly half (n=22) received systemic therapy within 12 weeks of surgery (data not shown). Among patients who received systemic therapy within 12 months postdiagnosis, 18.5% of patients with stage III disease and 9.1% of patients with stage IV disease participated in a clinical trial.

As shown in Table 2, the type of systemic agents received by patients with stage IV disease also changed markedly between 2004 and 2009. Use of IFN and IL-2, the systemic agents most commonly received by patients in 2004, significantly decreased from 16.6% to 3.0% (P=.04) and 16.3% to 2.2% (P<.01), respectively, by 2009. Sunitinib use significantly increased from 1.6% to 39.2% (P<.01) over the same period. Temsirolimus, approved by the FDA in 2007, was the second most commonly used systemic agent by 2009 (15.2%).

Figure 2 shows the Kaplan-Meier plot of time-to-systemic treatment, in days, by year of diagnosis. Patients with stage IV disease diagnosed in 2009 received systemic therapy sooner than those diagnosed in 2004. The median time-to-systemic treatment was approximately 93 days for patients diagnosed in 2009. Because less than 50% of patients diagnosed in 2004 received systemic therapy, we do not report median time-to-systemic treatment. Among patients with stage IV disease who received systemic therapy, the mean time-to-systemic treatment was 85.58 days (95% CI, 69.23, 101.94) and 68.63 days (95% CI, 57.86, 79.39) for patients diagnosed in 2004 and 2009, respectively (data not shown).

In multivariate analysis, patients diagnosed in 2009 were significantly more likely to receive systemic therapy than those diagnosed in 2004 (odds ratio, 3.62; 95% CI, 1.91, 6.87; Table 3). Patients who were younger and lived in areas with higher educational attainment had significantly higher odds of receiving systemic therapy than those who were older and lived in areas with lower educational attainment (P<.05). In this multivariate analysis of time-to-systemic treatment, patients diagnosed in 2009 (HR, 2.60; 95% CI, 1.69, 4.03), younger patients, and those residing in areas with higher levels of education had a shorter time-to-systemic treatment (P<.05).

Table 1

Characteristics of Patients by Year of Diagnosis

Table 1

In sensitivity analyses to assess the potential impact of trends in surgery on the time-to-systemic treatment analyses, the authors found that diagnosis in 2009 was associated with shorter time-to-systemic treatment for patients with stage IV disease who did and did not receive any surgery within 12 months postdiagnosis (HR, 3.87; 95% CI, 1.90, 7.92; and HR, 1.97; 95%CI, 0.94, 4.13, respectively; Table 4).

Discussion

Findings from this population-based study of patients with RCC in the United States highlight considerable changes in treatment patterns over time. Rapid diffusion of systemic treatments occurred after FDA approval of 7 new therapies between 2004 and 2009 for treatment of advanced RCC. Among patients with stage IV RCC, receipt of systemic therapy increased by 63% from 2004 to 2009, and significant decreases in both use of surgery before receipt of systemic treatment and time-to-systemic treatment are notable.

Although previous studies have examined patterns of care among patients with RCC who received specific targeted therapies,9-12 the authors believe theirs is the most comprehensive study examining systemic RCC treatment trends over time. They found a substantial increase in the use of systemic therapy for patients with stage IV RCC, from 35.7% in 2004 to 58.3% in 2009 (P<.001). Somewhat surprising, though, is the finding that nearly 40% of these patients did not receive any systemic therapy in 2009. However, it is possible that some of these stage IV patients started systemic treatment only after manifesting distant metastatic relapse, having nonmetastatic stage IV disease at diagnosis.

In the current study, sunitinib was the most commonly used systemic treatment for patients with stage IV RCC in 2009. This finding is consistent with that in a recent study by Hess et al12 reporting that sunitinib was the most frequent first-line therapy among 273 patients with metastatic RCC. The present results indicate that use of both IL-2 and IFN decreased markedly between 2004 and 2009, each from approximately 16% to 2% of patients receiving systemic therapy. Toxicity profiles demonstrated clinical efficacy and ease of administration of the newer agents likely explain these trends.13-15 Interestingly, formal FDA approval of IFN (in combination with bevacizumab) did not occur until 2009, although it has been used since the early 1990s in RCC treatment.16 Of the 8 commonly used FDA-approved agents (Table 2), 7 were approved since 2005. With mounting evidence of improved efficacy for many of these novel therapies (ie, temsirolimus, everolimus, pazopanib),17-19 it will be important to further monitor trends in their use.

Figure 1
Figure 1

Percentage of patients with renal cell cancer who received systemic therapy within 12 months of diagnosis by stage and year of diagnosis. P values based on chi-square test for difference in proportion of patients within each stage who received systemic therapy within 12 months between 2004 and 2009.

aIn this category, too few observations were available in a given cell to report (n<10).

bP≤.01.

cP≤.05.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 9; 10.6004/jnccn.2014.0124

Notably, the proportion of patients with stage III RCC receiving systemic therapy increased from 3.8% to 15.7% between 2004 and 2009, although the percentage of these patients participating in clinical trials was similar in both years (16% and 19%, respectively). It is possible that some of these patients received systemic treatment only after they manifested metastatic disease. Most patients with stage III disease underwent surgery before systemic treatment. The largest adjuvant treatment trial in patients with RCC in the United States, ASSURE (E2805; ClinicalTrials.gov identifier: NCT00326898), did not start until April 2006 and has the estimated primary completion date of April 2016. It is also possible that some patients with stage III RCC may have received systemic therapy as adjuvant off-label treatment based on disease with high-risk features.

Table 2

Type of Systemic Therapy Received by Patients With Stage IV RCC by Year of Diagnosisa

Table 2

The present finding of a 34% decrease in the proportion of patients with stage IV RCC who underwent nephrectomy before receipt of systemic treatment between 2004 and 2009 extends the existing research20-22 indicating a significant decline in the use of cytoreductive nephrectomy for patients with metastatic RCC after FDA approval of vascular endothelial growth factor receptor tyrosine kinase inhibitors (VEGFR-TKI; eg, after 2005). This decreased use of surgery represents a change in the direction of the trend, because rates had been increasing in the years immediately following the results from 2 randomized controlled trials (SWOG 8949 and EORTC 30947) in 2001.21-23 These 2 prospective randomized trials showed improved overall survival from cytoreductive nephrectomy in patients with metastatic RCC treated with IFN-α.24,25 Reluctance to subject patients to surgery given the availability of orally administered agents with proven clinical benefit may influence decision-making. There may also be reasonable doubts about the contribution of nephrectomy when combined with these novel systemic treatments. Two ongoing phase III randomized trials in Europe are evaluating the role of nephrectomy: CARMENA (ClinicalTrials.gov identifier: NCT00930033) is comparing sunitinib with or without nephrectomy, and SURTIME (EORTC-30073; ClinicalTrials.gov identifier: NCT01099423) is comparing sunitinib with immediate or deferred nephrectomy.

Figure 2
Figure 2

Kaplan-Meier plot of time-to-systemic treatment among patients with stage IV renal cell cancer by year of diagnosis. Estimates based on the number of patients with stage IV disease who received systemic therapy within 12 months, starting from date of diagnosis (or date of surgery for patients with stage IV who received surgery before systemic therapy). Log-rank test of equality, P<.01.

Citation: Journal of the National Comprehensive Cancer Network J Natl Compr Canc Netw 12, 9; 10.6004/jnccn.2014.0124

The significant decrease in time-to-systemic treatment within the first year after diagnosis for patients with stage IV RCC from 2004 to 2009 in the present study was likely influenced by many factors. Because patients undergoing a nephrectomy can start treatment only after adequate recovery from surgery, which would delay time to initiate systemic therapy, the authors accounted for receipt of surgery in their analysis. In addition, they conducted sensitivity analyses in which they found shorter times to systemic treatment in 2009 among patients treated with and without surgery.

Table 3

Factors Associated With Receipt of Systemic Therapy and Time-to-Systemic Treatment Within 12 Months of Diagnosis Among Patients With Stage IV Renal Cell Cancer

Table 3

Patient age and educational attainment in the area of residence were found to influence the odds of receiving systemic therapy and time-to-systemic treatment. Saigal et al26 reported similar findings of an inverse association between age at diagnosis and receipt of systemic therapy among patients with metastatic RCC. Although the current study controlled for the presence of comorbid conditions at diagnosis, the effect of age on both receipt of systemic therapy and time-to-systemic treatment is likely attributable to concerns about treatment tolerability. The authors’ results of a positive association between education and receipt of systemic therapy add to findings from prior studies that suggest lower levels of educational attainment influence the treatment received by patients with cancer,27-30 which may be linked to several factors, including the availability and access to medical care. Moreover, among patients with advanced-stage disease, those presenting too late in the course of the disease, with poor performance status, may be considered poor candidates for treatment because of the possible side effects.

Table 4

Results of Sensitivity Analyses of Time-to-Systemic Treatment Within 12 Months of Diagnosis Among Patients With Stage IV Renal Cell Cancer by Receipt of Surgery

Table 4

The results of the present study should be interpreted in the context of certain limitations. No data were available on the treating physician characteristics, including information on training and practice style, which has been shown to impact care delivery.31,32 Further, information on patient preferences or experiences was not collected. These data were not mature enough for a reliable comparison of survival in 2004 to 2009. Although the authors controlled for several predictors of interest, some unmeasured factors may have influenced the treatment of patients with RCC. Finally, among patients with stage IV disease, data on the development of distant metastatic disease after initial treatment were not available.

Conclusions

The present findings indicate that treatment for RCC in the United States has evolved toward increased use of systemic therapy over the past decade. Availability of several novel systemic therapeutic agents has led to increased treatment options for patients with advanced RCC. As the diffusion of new therapies continues, understanding of how variation in care for RCC will impact health outcomes will be imperative, including therapeutic benefit, quality of life, and costs of care.

This work was supported by National Cancer Institute contracts: HHSN261201000024C; HHSN261201000025C, HHSN261201000032C, HHSN261201000027C, HHSN261201000026C, HHSN261201000140C, HHSN261201000037C, HHSN261201000033C, HHSN261201000034C, HHSN261201000035C, HHSN261201000029C, HHSN261201000031C, HHSN261201000028C, and HHSN261201000030C. The authors have disclosed that they have no financial interests, arrangements, affiliations, or commercial interests with the manufacturers of any products discussed in this article or their competitors. This article is a US Government work and, as such, is in the public domain in the United States. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCI or NIH.

The authors would like to acknowledge the work of the SEER Cancer Registries. This research would not have been possible without their efforts.

References

  • 1.

    American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013. Available at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 2.

    Motzer RJ, Hutson TE, Tomczak P. Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med 2007;356:115124.

  • 3.

    Cohen HT, McGovern FJ. Renal-cell carcinoma. N Engl J Med 2005;353:24772490.

  • 4.

    Hutson TE. Targeted therapies for the treatment of metastatic renal cell carcinoma: clinical evidence. Oncologist 2011;16(Suppl 2):S1422.

    • Search Google Scholar
    • Export Citation
  • 5.

    Gross-Goupil M, Massard C, Ravaud A. Targeted therapies in metastatic renal cell carcinoma: overview of the past year. Curr Urol Rep 2012;13:1623.

    • Search Google Scholar
    • Export Citation
  • 6.

    Yabroff KR, Harlan L, Stevens J. Patterns of care in adults with renal cell carcinoma: findings in a population based sample. J Urol 2009;181:24622468; discussion 2469.

    • Search Google Scholar
    • Export Citation
  • 7.

    National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Number of Persons by Race and Hispanic Ethnicity for SEER Participants (2010 Census Data). Available at: http://seer.cancer.gov/registries/data.html. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 8.

    Motzer RJ, Jonasch E, Agarwal N. NCCN Clinical Practice Guidelines in Oncology: Kidney Cancer. Version 3.2014. Available at: NCCN.org. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 9.

    Filson CP, Redman BG, Dunn RL. Initial patterns of care with oral targeted therapies for patients with renal cell carcinoma. Urology 2011;77:825830.e1.

    • Search Google Scholar
    • Export Citation
  • 10.

    Choueiri TK, Duh MS, Clement J. Angiogenesis inhibitor therapies for metastatic renal cell carcinoma: effectiveness, safety and treatment patterns in clinical practice-based on medical chart review. BJU Int 2010;105:12471254.

    • Search Google Scholar
    • Export Citation
  • 11.

    Vogelzang NJ, Bhor M, Liu Z. Everolimus vs. temsirolimus for advanced renal cell carcinoma: use and use of resources in the US Oncology Network. Clin Genitourin Cancer 2013;11:115120.

    • Search Google Scholar
    • Export Citation
  • 12.

    Hess G, Borker R, Fonseca E. Treatment patterns: targeted therapies indicated for first-line management of metastatic renal cell carcinoma in a real-world setting. Clin Genitourin Cancer 2103;11:161167.

    • Search Google Scholar
    • Export Citation
  • 13.

    Motzer RJ, Hutson TE, Olsen MR. Randomized phase II trial of sunitinib on an intermittent versus continuous dosing schedule as first-line therapy for advanced renal cell carcinoma. J Clin Oncol 2012;30:13711377.

    • Search Google Scholar
    • Export Citation
  • 14.

    Motzer RJ, Hutson TE, Tomczak P. Overall survival and updated results for sunitinib compared with interferon alfa in patients with metastatic renal cell carcinoma. J Clin Oncol 2009;27:35843590.

    • Search Google Scholar
    • Export Citation
  • 15.

    Cella D, Michaelson MD, Bushmakin AG. Health-related quality of life in patients with metastatic renal cell carcinoma treated with sunitinib vs interferon-alpha in a phase III trial: final results and geographical analysis. Br J Cancer 2010;102:658664.

    • Search Google Scholar
    • Export Citation
  • 16.

    Minasian LM, Motzer RJ, Gluck L. Interferon alfa-2a in advanced renal cell carcinoma: treatment results and survival in 159 patients with long-term follow-up. J Clin Oncol 1993;11:13681375.

    • Search Google Scholar
    • Export Citation
  • 17.

    Armstrong AJ, George DJ, Halabi S. Serum lactate dehydrogenase predicts for overall survival benefit in patients with metastatic renal cell carcinoma treated with inhibition of mammalian target of rapamycin. J Clin Oncol 2012;30:34023407.

    • Search Google Scholar
    • Export Citation
  • 18.

    Sternberg CN, Davis ID, Mardiak J. Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial. J Clin Oncol 2010;28:10611068.

    • Search Google Scholar
    • Export Citation
  • 19.

    Calvo E, Escudier B, Motzer RJ. Everolimus in metastatic renal cell carcinoma: subgroup analysis of patients with 1 or 2 previous vascular endothelial growth factor receptor-tyrosine kinase inhibitor therapies enrolled in the phase III RECORD-1 study. Eur J Cancer 2012;48:333339.

    • Search Google Scholar
    • Export Citation
  • 20.

    Tsao CK, Small AC, Kates M. Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis. World J Urol, 2013;31:15351539.

    • Search Google Scholar
    • Export Citation
  • 21.

    Tsao CK, Small AC, Moshier EL. Trends in the use of cytoreductive nephrectomy in the United States. Clin Genitourin Cancer 2012;10:159163.

  • 22.

    Conti SL, Thomas IC, Hagedorn JC. Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era. Int J Cancer 2014;134;22452252.

    • Search Google Scholar
    • Export Citation
  • 23.

    Jeldres C, Baillargeon-Gagne S, Liberman D. A population-based analysis of the rate of cytoreductive nephrectomy for metastatic renal cell carcinoma in the United States. Urology 2009;74:837841.

    • Search Google Scholar
    • Export Citation
  • 24.

    Flanigan RC, Salmon SE, Blumenstein BA. Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 2001;345:16551659.

    • Search Google Scholar
    • Export Citation
  • 25.

    Mickisch GH, Garin A, van Poppel H. Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial. Lancet 2001;358:966970.

    • Search Google Scholar
    • Export Citation
  • 26.

    Saigal CS, Deibert CM, Lai J. Disparities in the treatment of patients with IL-2 for metastatic renal cell carcinoma. Urol Oncol 2010;28:308313.

    • Search Google Scholar
    • Export Citation
  • 27.

    Stitzenberg KB, Sanoff HK, Penn DC. Practice patterns and long-term survival for early-stage rectal cancer. J Clin Oncol 2013;31:42764282.

  • 28.

    Kane CJ, Lubeck DP, Knight SJ. Impact of patient educational level on treatment for patients with prostate cancer: data from CaPSURE. Urology 2003;62:10351039.

    • Search Google Scholar
    • Export Citation
  • 29.

    Baldwin LM, Dobie SA, Billingsley K. Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst 2005;97:12111220.

    • Search Google Scholar
    • Export Citation
  • 30.

    Ballard-Barbash R, Potosky AL, Harlan LC. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst 1996;88:716726.

    • Search Google Scholar
    • Export Citation
  • 31.

    Miller DC, Saigal CS, Banerjee M. Diffusion of surgical innovation among patients with kidney cancer. Cancer 2008;112:17081717.

  • 32.

    Malin JL, Weeks JC, Potosky AL. Medical oncologists’ perceptions of financial incentives in cancer care. J Clin Oncol 2013;31:530535.

If the inline PDF is not rendering correctly, you can download the PDF file here.

Correspondence: Matthew P. Banegas, PhD, MPH, National Cancer Institute, 9609 Medical Center Drive, MSC 9762, Bethesda, MD 20892-9762. E-mail: banegasmp@mail.nih.gov
  • View in gallery

    Percentage of patients with renal cell cancer who received systemic therapy within 12 months of diagnosis by stage and year of diagnosis. P values based on chi-square test for difference in proportion of patients within each stage who received systemic therapy within 12 months between 2004 and 2009.

    aIn this category, too few observations were available in a given cell to report (n<10).

    bP≤.01.

    cP≤.05.

  • View in gallery

    Kaplan-Meier plot of time-to-systemic treatment among patients with stage IV renal cell cancer by year of diagnosis. Estimates based on the number of patients with stage IV disease who received systemic therapy within 12 months, starting from date of diagnosis (or date of surgery for patients with stage IV who received surgery before systemic therapy). Log-rank test of equality, P<.01.

  • 1.

    American Cancer Society. Cancer Facts & Figures 2013. Atlanta, GA: American Cancer Society; 2013. Available at: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-036845.pdf. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 2.

    Motzer RJ, Hutson TE, Tomczak P. Sunitinib versus interferon alfa in metastatic renal-cell carcinoma. N Engl J Med 2007;356:115124.

  • 3.

    Cohen HT, McGovern FJ. Renal-cell carcinoma. N Engl J Med 2005;353:24772490.

  • 4.

    Hutson TE. Targeted therapies for the treatment of metastatic renal cell carcinoma: clinical evidence. Oncologist 2011;16(Suppl 2):S1422.

    • Search Google Scholar
    • Export Citation
  • 5.

    Gross-Goupil M, Massard C, Ravaud A. Targeted therapies in metastatic renal cell carcinoma: overview of the past year. Curr Urol Rep 2012;13:1623.

    • Search Google Scholar
    • Export Citation
  • 6.

    Yabroff KR, Harlan L, Stevens J. Patterns of care in adults with renal cell carcinoma: findings in a population based sample. J Urol 2009;181:24622468; discussion 2469.

    • Search Google Scholar
    • Export Citation
  • 7.

    National Cancer Institute. Surveillance, Epidemiology, and End Results Program. Number of Persons by Race and Hispanic Ethnicity for SEER Participants (2010 Census Data). Available at: http://seer.cancer.gov/registries/data.html. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 8.

    Motzer RJ, Jonasch E, Agarwal N. NCCN Clinical Practice Guidelines in Oncology: Kidney Cancer. Version 3.2014. Available at: NCCN.org. Accessed July 31, 2014.

    • Search Google Scholar
    • Export Citation
  • 9.

    Filson CP, Redman BG, Dunn RL. Initial patterns of care with oral targeted therapies for patients with renal cell carcinoma. Urology 2011;77:825830.e1.

    • Search Google Scholar
    • Export Citation
  • 10.

    Choueiri TK, Duh MS, Clement J. Angiogenesis inhibitor therapies for metastatic renal cell carcinoma: effectiveness, safety and treatment patterns in clinical practice-based on medical chart review. BJU Int 2010;105:12471254.

    • Search Google Scholar
    • Export Citation
  • 11.

    Vogelzang NJ, Bhor M, Liu Z. Everolimus vs. temsirolimus for advanced renal cell carcinoma: use and use of resources in the US Oncology Network. Clin Genitourin Cancer 2013;11:115120.

    • Search Google Scholar
    • Export Citation
  • 12.

    Hess G, Borker R, Fonseca E. Treatment patterns: targeted therapies indicated for first-line management of metastatic renal cell carcinoma in a real-world setting. Clin Genitourin Cancer 2103;11:161167.

    • Search Google Scholar
    • Export Citation
  • 13.

    Motzer RJ, Hutson TE, Olsen MR. Randomized phase II trial of sunitinib on an intermittent versus continuous dosing schedule as first-line therapy for advanced renal cell carcinoma. J Clin Oncol 2012;30:13711377.

    • Search Google Scholar
    • Export Citation
  • 14.

    Motzer RJ, Hutson TE, Tomczak P. Overall survival and updated results for sunitinib compared with interferon alfa in patients with metastatic renal cell carcinoma. J Clin Oncol 2009;27:35843590.

    • Search Google Scholar
    • Export Citation
  • 15.

    Cella D, Michaelson MD, Bushmakin AG. Health-related quality of life in patients with metastatic renal cell carcinoma treated with sunitinib vs interferon-alpha in a phase III trial: final results and geographical analysis. Br J Cancer 2010;102:658664.

    • Search Google Scholar
    • Export Citation
  • 16.

    Minasian LM, Motzer RJ, Gluck L. Interferon alfa-2a in advanced renal cell carcinoma: treatment results and survival in 159 patients with long-term follow-up. J Clin Oncol 1993;11:13681375.

    • Search Google Scholar
    • Export Citation
  • 17.

    Armstrong AJ, George DJ, Halabi S. Serum lactate dehydrogenase predicts for overall survival benefit in patients with metastatic renal cell carcinoma treated with inhibition of mammalian target of rapamycin. J Clin Oncol 2012;30:34023407.

    • Search Google Scholar
    • Export Citation
  • 18.

    Sternberg CN, Davis ID, Mardiak J. Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial. J Clin Oncol 2010;28:10611068.

    • Search Google Scholar
    • Export Citation
  • 19.

    Calvo E, Escudier B, Motzer RJ. Everolimus in metastatic renal cell carcinoma: subgroup analysis of patients with 1 or 2 previous vascular endothelial growth factor receptor-tyrosine kinase inhibitor therapies enrolled in the phase III RECORD-1 study. Eur J Cancer 2012;48:333339.

    • Search Google Scholar
    • Export Citation
  • 20.

    Tsao CK, Small AC, Kates M. Cytoreductive nephrectomy for metastatic renal cell carcinoma in the era of targeted therapy in the United States: a SEER analysis. World J Urol, 2013;31:15351539.

    • Search Google Scholar
    • Export Citation
  • 21.

    Tsao CK, Small AC, Moshier EL. Trends in the use of cytoreductive nephrectomy in the United States. Clin Genitourin Cancer 2012;10:159163.

  • 22.

    Conti SL, Thomas IC, Hagedorn JC. Utilization of cytoreductive nephrectomy and patient survival in the targeted therapy era. Int J Cancer 2014;134;22452252.

    • Search Google Scholar
    • Export Citation
  • 23.

    Jeldres C, Baillargeon-Gagne S, Liberman D. A population-based analysis of the rate of cytoreductive nephrectomy for metastatic renal cell carcinoma in the United States. Urology 2009;74:837841.

    • Search Google Scholar
    • Export Citation
  • 24.

    Flanigan RC, Salmon SE, Blumenstein BA. Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. N Engl J Med 2001;345:16551659.

    • Search Google Scholar
    • Export Citation
  • 25.

    Mickisch GH, Garin A, van Poppel H. Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomised trial. Lancet 2001;358:966970.

    • Search Google Scholar
    • Export Citation
  • 26.

    Saigal CS, Deibert CM, Lai J. Disparities in the treatment of patients with IL-2 for metastatic renal cell carcinoma. Urol Oncol 2010;28:308313.

    • Search Google Scholar
    • Export Citation
  • 27.

    Stitzenberg KB, Sanoff HK, Penn DC. Practice patterns and long-term survival for early-stage rectal cancer. J Clin Oncol 2013;31:42764282.

  • 28.

    Kane CJ, Lubeck DP, Knight SJ. Impact of patient educational level on treatment for patients with prostate cancer: data from CaPSURE. Urology 2003;62:10351039.

    • Search Google Scholar
    • Export Citation
  • 29.

    Baldwin LM, Dobie SA, Billingsley K. Explaining black-white differences in receipt of recommended colon cancer treatment. J Natl Cancer Inst 2005;97:12111220.

    • Search Google Scholar
    • Export Citation
  • 30.

    Ballard-Barbash R, Potosky AL, Harlan LC. Factors associated with surgical and radiation therapy for early stage breast cancer in older women. J Natl Cancer Inst 1996;88:716726.

    • Search Google Scholar
    • Export Citation
  • 31.

    Miller DC, Saigal CS, Banerjee M. Diffusion of surgical innovation among patients with kidney cancer. Cancer 2008;112:17081717.

  • 32.

    Malin JL, Weeks JC, Potosky AL. Medical oncologists’ perceptions of financial incentives in cancer care. J Clin Oncol 2013;31:530535.

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