Sociodemographic Disparities in the Nonoperative Management of Small Renal Masses

Nurse Navigators' Views on Patient and System Factors Associated with Navigation Needs among Women with Breast Cancer

Coordinating breast cancer treatment is a complex task that can overwhelm patients and their support networks. Though the Cancer Patient Navigator (CPN) program in Nova Scotia (NS) provides professional assistance to patients, certain groups of patients may still face barriers to accessing its services. Employing interviews and a modified Delphi approach with CPN participants, this study sought to identify factors associated with the need for navigation to help better target CPN program referrals among breast cancer patients. Six CPNs were recruited directly through the CPN program manager for interviews and surveys. The CPNs identified 27 different factors, which were divided into 4 categories: sociodemographic, psychological, clinical and health systems. While these patient factors (particularly sociodemographic) are not directly modifiable, awareness of their association with the need for navigation could be used to better target patients with a high need for navigation for referral to CPN services.

Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass

CONTEXT

With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced.

OBJECTIVE

To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making.

CONCLUSIONS

Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care.

PATIENT SUMMARY

With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

Comparative effectiveness in urology: a state of the art review utilizing a systematic approach

PURPOSE OF REVIEW

Comparative effectiveness research plays a vital role in healthcare delivery by guiding evidence-based practices. We performed a state-of-the-art review of comparative effectiveness research in the urology literature for 2016, utilizing a systematic approach. Seven high-impact papers are reviewed in detail.

RECENT FINDINGS

Across the breadth of urology, there were several important studies in comparative effectiveness research, of which we will highlight two randomized controlled trials and five observational trials: radiotherapy, prostatectomy, and active monitoring have equivalent mortality outcomes in patients with localized prostate cancer; the ideal modality of patient education is yet to be determined, and written education has minimal effect on patient perception of prostate specific antigen screening; robotic prostatectomy is associated with higher perioperative complication rates on a population basis; racial disparities exist in incontinence rates after treatment for localized prostate cancer, but not in irritative, bowel, or sexual function; androgen deprivation therapy is associated with higher fracture, peripheral artery disease, and cardiac-related complications than bilateral orchiectomy; robotic and open cystectomy offer comparable cancer-specific mortality and perioperative outcomes; and bonuses for low-cost hospitals can inadvertently reward low-quality hospitals.

SUMMARY

There have been major advancements in comparative effectiveness research in urology in 2016.

Marital status and gender affect stage, tumor grade, treatment type and cancer specific mortality in T1-2 N0 M0 renal cell carcinoma

PURPOSE

To examine the effect of marital status and gender on stage at diagnosis, tumor grade, treatment type and cancer specific mortality (CSM) in patients with localized renal cell carcinoma (RCC).

METHODS

Within Surveillance, Epidemiology, and End Results registry (2001-2013), we identified 57,700 patients with T_1-2 N₀ M₀ RCC. Logistic regression and competing-risks regression models tested the effect of marital status and gender on stage, tumor grade, treatment type and cancer specific mortality (CSM).

RESULTS

Of all patients, 8.8, 10.6 and 14.8% were, respectively, widowed, separated/divorced and never married. The three categories accounted for 3.9, 9.0 and 14.9% of males (35,641) and for 16.7, 13.1 and 14.7% of females (22,059). Widowed (OR 1.13, p = 0.04), separated/divorced (OR 1.16, p = 0.02) and never married status (OR 1.38, p < 0.001) predisposed to higher rate of no surgical treatment. Widowed (HR 1.32, p < 0.001) and separated/divorced (HR 1.32, p < 0.001) status predisposed to higher CSM. Male gender predisposed to higher T-stage (OR 1.12, p < 0.001), higher tumor grade (OR 1.35, p < 0.001), no surgical treatment (OR 1.23, p < 0.001) and higher CSM (1.13, p = 0.01). Interaction tests between gender and marital status failed to reach independent predictor status in all analyses.

CONCLUSIONS

Male patients are at higher risk of less favorable baseline characteristics. Additionally, male, widowed and separated/divorced patients exhibit worse cancer control outcomes after treatment for T_1-2 N₀ M₀ RCC. These observations indicate the need of more focused attention to those patients prior to, as well as after treatment for localized RCC.

Impact of tumor size on the outcome of patients with small renal cell carcinoma

BACKGROUND

​This study aims to establish potential correlation between tumor size and outcomes in patients with T1a kidney cancer registered within the surveillance, epidemiology and end results (SEER) database.

METHODS

SEER database (2004-2013) has been accessed through SEER*Stat program to determine the correlation between tumor size and cancer-specific survival in patients with T1a kidney cancer.  Survival analysis was conducted through Kaplan-Meier analysis and log-rank testing.

RESULTS

Five year kidney cancer-specific survival rates show progressive decline with increasing tumor size.  Moreover, kidney cancer-specific survival has been compared according to the initial local treatment modality (observation, ablation, partial or radical nephrectomy) across different size categories (<1 cm, 1-2 cm, 2-3 cm and 3-4 cm).  Survival curves of different treatment modalities were almost overlapping for patients with renal mass < 1cm. For patients with tumor size 1-2 cm, treatment modalities were overlapping at the first 60 months then the curve of observation diverged (P <0.0001). For patients with tumor size 2-3 cm and 3-4 cm, the curve of observation diverged early in the time course (P <0.0001).

CONCLUSION

Primary tumor size is an important factor that should be taken into consideration when evaluating the different treatment options for patients with small kidney cancers.​.

Update on active surveillance for clinical T1 renal tumors

PURPOSE OF REVIEW

The purpose is to discuss current data on the utilization and outcomes of active surveillance for T1a renal masses. Specifically, to address which patients are optimal for active surveillance and how their outcomes differ from those undergoing immediate treatment.

RECENT FINDINGS

Although nephron sparing surgery is the standard of care for small renal masses (SRMs), active surveillance is becoming a more popular intervention given the results of prospective studies revealing active surveillance to be safe and have excellent cancer-specific survival with intermediate follow-up. Older and sicker patients have competing risk of death from other causes when diagnosed with a SRM.

SUMMARY

Active surveillance is becoming a more popular treatment modality for SRMs given the increasing number of incidental diagnoses and better understanding of their often indolent course. Active surveillance with delayed intervention is a well-tolerated treatment modality and appears to have the most benefit for those patients that are older with more comorbidities.