Urologic Oncology: Seminars and Original Investigations
Clinical-Kidney cancerThe association between facility case volume and overall survival in patients with metastatic renal cell carcinoma in the targeted therapy era
Introduction
Renal cell carcinoma (RCC) has an estimated 63,990 new cases and 14,400 deaths in 2017 [1]. While the RCC survival rate had been traditionally poor, the 5-year survival rate had increased from 57% in 1987 to 1989 to 74% in 2006 to 2012 [1]. This improvement is likely due to 2 main factors: first is the diffuse use of imaging studies which resulted in increased detection of early-stage disease [2], [3]; the other is the targeted therapy (TT) era for advanced RCC beginning at the end of 2005 with 7 antiangiogenic drugs and 2 mammalian target of rapamycin inhibitors approved from 2005 to 2016 by the Food and Drug Administration [4]. Prior to the approval of nivolumab in November 2015 as second-line therapy for metastatic renal cell carcinoma (mRCC), the fundamental treatment for mRCC was TT with or without cytoreductive nephrectomy (CN) [5]. With such advancement in mRCC treatment since the end of 2005, the expertise of the treating facilities to keep up with new knowledge is essential in order to achieve the best patient outcomes.
In surgical oncology [6], [7], [8], [9], [10], [11], [12], there has been well-established evidence that surgical expertise improves with higher hospital/surgeon volume, which is reflected in decreased postoperative mortality [6], [7], higher rate of achieving negative margins [8], [10], [13], a higher yield in lymph node dissection [8], [10], [11], [12], [13] and improved long term survival [6], [7], [8], [9], [10], [11], [12]. In radiation oncology [14], [15], [16], [17], [18], there is also emerging evidence demonstrating improved overall survival in patients treated at high-volume facilities. However, there are limited data whether this volume -outcome association exists in hematology-oncology managed cancers [19], [20], [21], [22] especially in advanced solid tumors. Thus, the association between facility case volume (FCV) and overall survival (OS) in mRCC patients in the targeted therapy era was investigated. It was hypothesized that mRCC patients treated at high mRCC case volume facilities may have improved overall survival.
Section snippets
2.1. Data source
The National Cancer Database (NCDB) Participant Use Data File, which is a joint quality improvement program of the American College of Surgeons Commission on Cancer (CoC) and the American Cancer Society, was the data source for the present analysis. NCDB prospectively collects patient and facility characteristics. It captures 70% of newly diagnosed cancer cases in the United States [23] and is the largest cancer registry in the world. This study was exempted from review by Institutional Review
3.1. Baseline characteristics
There were 31,329 patients diagnosed with mRCC in 2006 to 2015 (Table 1). The median age at diagnosis was 64 (interquartile range 56–74). 20,699 (66.1%) were male. Overall, 14,690 patients (46.9%) received TT, 8,398 (26.8%) patients received CN, 3,663 (11.7%) received metastasectomy and 8,402 (26.8%) had radiation in the first treatment course. There were 11,339 (36.2%) patients treated in academic facilities.
3.2. Association between facility case volume and mRCC overall survival
The mean follow-up time was 14.3 months (median: 6.4 months, 95% confidence interval
Discussion
The present analysis is the first to demonstrate a volume-outcome association in a pure metastatic disease cohort of solid tumor patients. Using the largest hospital-based cancer database in the United States, it was demonstrated that increased FCV of mRCC cases was associated with improved overall survival in mRCC patients. This improved outcome was illustrated in contemporary patients treated at the top 5% facilities by mRCC volume with a 10% risk reduction in all-cause mortality. The major
Conclusions
In conclusion, patients with mRCC had improved overall survival if treated at high mRCC-volume facilities. These results suggest that expertise of the treating medical oncologists is gained through accumulating experience in daily practice similar to improved outcomes observed in high-volume providers of surgical oncology [6], [7], [8], [9] and radiation oncology [14], [15], [16], [17], [18] and have implications for delivery of quality oncology care.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Conflict of interest disclosures
Yu-Wei Chen and Jennifer Beach: none. Moshe C. Ornstein consulted for Pfizer. Laura S. Wood consulted for Exelixis. Kimberly D Allman consulted for Exelixis. Allison Martin consulted for Pfizer. Timothy Gillgan consulted for WellPoint. Jorge A. Garcia consulted for Sanofi, Pfizer, Bayer HealthCare Pharmaceuticals, Eisai, Exelixis, Medivation, and Genentech/Roche. Brian I. Rini consulted for Pfizer, Merck, and Corvus Pharmaceuticals.
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