The past few weeks have had me thinking: can Americans adapt to a message in medicine that "less is more," when science confirms it?
Back in April, at the American Urological Association (AUA) annual meeting, the AUA issued its first-ever guideline for the treatment of early-stage kidney cancer. It is actually good news for patients.
The guideline states that the kidney should be saved whenever possible. Complete removal of the kidney [in early-stage kidney cancer]"puts patients at risk for chronic kidney disease and cardiovascular disease," according to the AUA.
In recent years, the number of people diagnosed with early-stage kidney cancer who had their kidneys removed rose dramatically. Many were diagnosed when they had no symptoms and only had their cancers identified through an imaging study done for another reason. Many people thought that they were doing well because the kidney was totally removed, when the cancer was confined to a relatively small part of the kidney.
AUA's specific recommendations for early-stage kidney cancer state that any of the following are reasonable treatment options:
- partial removal of the kidney
- thermal ablation, which uses heat to remove cancerous tissue
- active surveillance
According to the AUA, these treatments "minimize risks and are viable options for patients with early-stage kidney cancer."
Does the average patient with early-stage kidney cancer know of these new guidelines? Do urology oncologists treating kidney cancer follow these guidelines? It is probably much too soon to tell.
Taken in the context of the conflicts in the past few weeks over recommendations for less PSA screening, less breast cancer screening, and less cervical cancer screening, I commend the AUA and other physician organizations for reviewing the balance of benefits and harms in treating early-stage kidney cancer more aggressively.
I remember all too well the ruckus that ensued after a landmark clinical trial revealed that a lumpectomy resulted in no compromise in cancer control, yet spared the breast of women with early-stage breast cancer.
I think that it is going to take awhile for the American public to get used to thinking that less imaging, less screening, and less treatment in certain cases could possibly be better than more. Even though it has been a rocky start, we are taking some very positive steps.
Related Links
Guideline for the Management of the Clinical Stage I Renal Mass American Urological Association, 2009.
American Cancer Society. Detailed guide. What are the key statistics for kidney cancer? American Cancer Society, 2009.
There was an interesting case raising these issues in the New England Journal of Medicine recently. A man with kidney cancer (actually ureteral cancer) refused to have his one remaining kidney removed, because he would have to go on dialysis. He preferred to risk a return of kidney cancer than have to suffer with dialysis.
(They’ve had a number of cases in which patients refused invasive surgery, like prostatectomy or removing the remaining kidney, and wound up OK.)
24 Sep 2009, 361(13):1292, Case 30-2009: A 77-year-old man with recurrent transitional-cell carcinoma of the ureter, Donald S. Kaufman et al.
69-year-old man got transitional cell carcinoma in the right kidney and ureter, which were removed.
8 years later (age 77), TCC came back in left ureter. Doctor recommended removing left ureter, and if it extended into the kidney, remove the remaining kidney too and go on dialysis.
Average survival of 60-year-old man on dialysis is 5 years (at age 77, much less). Quality of life on dialysis sucks.
Patient refused to undergo surgery unless they would assure him they wouldn’t remove the kidney.
Finally got surgery at “another hospital” where they agreed in advance not to remove the kidney.
Fortunately cancer didn’t involve the renal pelvis, so at the other hospital they made an anastamosis from the kidney to the bladder out of ileum.
2 years later, no recurrence of TCC.
Case illustrates:
(1) Survived grade 3 TCC 10 years, longer than you’d expect.
(2) TCC requires lifelong surveillance.
(3) Hard to figure out where TCC of the upper urinary tract actually extends.
(4) Quality of life is so important to patients, they’d risk recurrence to avoid dialysis.
Interesting article. Certainly for early-stage asymptomatic KC this might be reasonable. In addition, when an individual has one kidney, it is often the case that the cancer will be treated without removing the kidney.
That said, it is very important to remember that for KC which shows symptoms or for larger tumors, nephrectomy is the way to go. Removal does have its own rosks — I had one kidney removed due to KC, developed HBP. Fortunately the remaining kidney funstions well with no signs of metastases.