Active Surveillance Proving Safe for Small Kidney Cancers
Allaf and Pierorazio: Many patients can be followed safely without the need for surgery.
Although the incidence of kidney cancer has increased dramatically over the last few decades, research led by Brady physicians is showing that many patients can be followed safely without the need for surgery.
Five years ago, Brady urologists Phillip Pierorazio, M.D., and Mohamad Allaf, M.D., began the Delayed Intervention and Surveillance for Small Renal Masses (DISSRM) Registry, following patients with small, localized kidney tumors (4 centimeters or smaller, and confined to the kidney), who choose either active surveillance or immediate surgery. "The patients undergoing surveillance have done incredibly well,” Pierorazio says. "No one has died of kidney cancer.” More than 450 patients at Hopkins, Columbia University, and Beth Israel Deaconess Medical Center are in the Registry; of those, about 55 percent have chosen surgery, and 40 percent have chosen surveillance. About 5 percent of those in the surveillance group later opted for surgery. In the 1970s, about 30,000 Americans were diagnosed yearly with kidney cancer; that number has jumped to about 60,000 today, in large part because of increasing use of CT scans. But still, the number of annual deaths – between 10,000 and 13,000 – has remained unchanged, Pierorazio notes. "So we’re operating on all these people, but we have not significantly changed the mortality of this disease. Which begs the question, are all of these tumors of consequence?” Is there overtreatment of these cancers? Although several institutions have studied surveillance, the studies have been mainly retrospective. Hopkins is one of three institutions worldwide with this kind of prospective protocol.
"The patients undergoing active surveillance have done incredibly well.”
Once it escapes the kidney, cancer is fatal. Surgical cure rates for kidneyconfined tumors are excellent – about 95 percent. And yet: "If you took everybody in this country with a small kidney tumor, anything 4 cm or less ,” says Pierorazio, "upwards of 30 percent are benign lesions – not e ven cancer. Of the 70 percent left, half are lowgrade, indolent tumors. They’re not ever going to cause a pr oblem. That only leaves about a third that are potentially aggressive.”
Who can safely avoid surgery? Pierorazio and colleagues have come up with a score based on some key clinical factors. For example: Tumors that are close to the renal hilum tend to be mor e aggressive. Women are more likely to have benign tumors, and older people are more likely to have indolent tumors. The risk of metastasis is extremely low in tumors under 2 centimeters . Surveillance is better for people with heart problems, particularly congestive heart failure.
With urologist Mohamad Allaf, M.D., Pierorazio runs a clinic for people with small kidney tumors. All in one day, patients get an ultrasound and labwork, then meet with a physician. "For patients who decide they want surgery, it’s very easy. We offer basically every option there is,” including complex partial, open-incision and robotic procedures. Patients who choose surveillance receive ultrasound every six months for the first two years, then annually.
"The DISSRM Registry is just one of the programs that keep the Brady at the forefront of urologic oncology research,” says Trinity Bivalacqua, M.D., Ph.D., Director of Urologic Oncology. "These early results will undoubtedly define how small renal masses are managed in the future.”