Elsevier

European Urology

Volume 74, Issue 3, September 2018, Pages 387-393
European Urology

Kidney Cancer
Treatment Facility Volume and Survival in Patients with Metastatic Renal Cell Carcinoma: A Registry-based Analysis

https://doi.org/10.1016/j.eururo.2018.05.025Get rights and content

Abstract

Background

Higher treatment facility (TF) volume has been linked with improved oncologic treatment outcomes.

Objective

To determine the association between TF volume and overall survival in patients with metastatic renal cell carcinoma (mRCC).

Design, setting, and participants

The National Cancer Database (NCDB) was queried for all patients with mRCC with survival data available (2004–2013, cohort A). Overall survival was assessed based on TF volumes, and increasingly narrow inclusion criteria were used to confirm the cohort A association: cohort B = mRCC patients with active treatment; cohort C = mRCC patients with systemic therapy; cohort D = mRCC patients with systemic therapy at the reporting institution; and cohort E = mRCC patients with systemic therapy at the reporting institution with known liver and lung metastatic status. Sensitivity analyses were also performed on subcohorts of mRCC who never underwent a nephrectomy (C1, D1, and E1).

Outcome measurements and statistical analysis

The effect of volume on time to death (from any cause) was determined using Cox regression models, adjusting for multiple clinical pathologic factors. Volume effects (assessed continuously) were modeled using flexible cubic splines, and adjusted 1-yr survivals were obtained from the model.

Results and limitations

A total of 41 836 mRCC patients were treated at 1222 TFs. The median age was 65 yr. Of the patients, 66% were men and 79% had clear cell mRCC. Median TF volume was 2.2 patients per year (pts/yr). Across all cohorts, higher TF volume was associated with improved outcomes. Adjusted 1-yr survival in cohort A was 0.36 at 2 pts/yr, 0.39 at 5 pts/yr, 0.42 at 10 pts/yr, and 0.46 at 20 pts/yr, with similar magnitudes of effect in cohorts B–E. Limitations include the retrospective nature of NCDB analysis and the lack of information on treatment regimens used at specific facilities, which may explain mechanisms of effects.

Conclusions

Higher facility volume is associated with improvements in survival for patients being treated for mRCC. Steps should be taken to standardize management of mRCC patients, such as evidence-based pathway development, clinical trial access, and multidisciplinary resource availability at lower-volume TFs.

Patient summary

In this report, we analyzed a large cancer database and found that patients with metastatic kidney cancer survived longer if they were managed at facilities that treated a higher volume of such patients. This information can help find the best treatment environment for patients with metastatic kidney cancer.

Introduction

Although mortality rates for patients with renal cell carcinoma (RCC) have declined over several decades, survival following the diagnosis of metastatic RCC (mRCC) continues to be poor [1]. Metastatic RCC is often an aggressive disease that is poorly responsive to traditional cytotoxic systemic therapies, with the 5-yr overall survival (OS) for patients as low as 8%, leading to over 14 000 deaths from RCC annually [1], [2].

The landscape for systemic mRCC therapy has rapidly evolved over the last 10 yr, first with improvements in targeted therapies and more recently with the development of novel immunotherapies. Advanced knowledge of these ever-changing treatment options may be necessary to obtain optimal patient outcomes. Centers that manage higher volumes of cancer patients likely employ providers that have such advanced knowledge and treatment experience, as well as access to novel drugs via clinical trials. Indeed, treatment volume has historically been used as a surrogate marker for hospital and provider experience, and may also indicate the presence of more streamlined care processes that can impact patient outcomes.

The volume-outcome relationship of various medical treatments and procedures has long been established, although the magnitude of this association varies greatly [3], [4]. This relationship also appears to hold true for cancer therapies, with mounting evidence to suggest that treatment facilities (TFs) that manage a higher volume of cancer patients might have improved survival outcomes [5], [6], [7], [8], [9].

For RCC, the volume-outcome relationship has been explored for the treatment of localized disease. Many studies have demonstrated that high-volume TFs lead to improved postoperative outcomes and fewer complications following renal cancer surgery [10], [11], [12]. Several studies showed improved in-hospital survival following high-risk nephrectomy for RCC, although it is unclear if surgery at high-volume surgical centers necessarily translates to overall longer-term survival [13], [14]. However, there is little knowledge regarding the volume-outcome relationship for patients diagnosed with and treated for mRCC. We, therefore, analyzed a large national cancer database to determine if there is a relationship between TF volume and survival outcomes for patients diagnosed with mRCC.

Section snippets

Data source

The National Cancer Database (NCDB), a program of the ACS CoC (Commission on Cancer) and the American Cancer Society, is a national cancer registry and comprehensive clinical surveillance resource for cancer care in the USA. The NCDB compiles data from over 1500 commission-accredited cancer programs in the USA and Puerto Rico, and captures approximately 70% of all newly diagnosed cancer cases [15]. The use of national deidentified registry data was exempt from institutional review board

Patient characteristics

A total of 41 836 mRCC patients were treated at 1222 TFs (Table 1). The median patient age was 65 yr, and men comprised 66% of the cohort. Of the patients, 86% were Caucasian and 10% African American. Of the patients, 79% had clear cell mRCC, followed by 17% having “other mRCC,” 3.5% papillary mRCC, and 0.7% chromophobe mRCC. The majority of patients had a Charlson-Deyo comorbidity score of “0.”

Treatment and facility characteristics

A large proportion of patients lived in large metropolitan areas (47%), followed by small

Discussion

The management of mRCC is becoming increasingly complex, and understanding the optimal environment for care delivery and resource utilization for patients diagnosed with this aggressive and relatively uncommon disease is important. Our retrospective analysis of 41 836 patients in the NCDB finds that for patients presenting with mRCC, overall mortality decreased as TF volume increased (5 pts/yr, HR = 0.92; 10 pts/yr, HR = 0.84; 20 pts/yr, HR = 0.74). The OS benefit resulting from higher TF volume

Conclusions

Higher facility volume is associated with improvements in survival for patients being treated for mRCC. This association was strengthened as TF volume increased. These findings may help define the optimal treatment environment for the management of patients with mRCC. The improved survival outcomes at higher-volume TFs should also be a call to improve mRCC management at lower-volume facilities. Given the negative externalities of care regionalization, focus should shift toward policies that

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