During the peak of the COVID-19 pandemic, several elective surgeries for renal cell carcinoma, the most common type of kidney cancer, were delayed with unknown impact on outcomes for patients.
In a retrospective study, researchers at Rutgers Cancer Institute of New Jersey explored the impact of surgery delays for these patients throughout the United States by utilizing the National Cancer Database to explore outcomes of patients who underwent surgery up to and after three months post diagnosis.
Results of the work are being presented as a poster presentation at the virtual American Society of Clinical Oncology (ASCO) 2021 Genitourinary Cancers Symposium by presenting author Arnav Srivastava, MD, MPH, Rutgers Robert Wood Johnson Medical School urology resident, along with senior author Eric A. Singer, MD, MA, MS, FACS, associate chief of Urology and Urologic Oncology and director of the Kidney Cancer Program at Rutgers Cancer Institute and associate professor of surgery and radiology at Rutgers Robert Wood Johnson Medical School. They share more about the work:
Why is this topic important to explore?
COVID-19 completely transformed society and disrupted healthcare delivery, in many instances. In an effort to preserve healthcare resources and curb the pandemic's exponential growth, hospitals deferred nonemergent surgeries. The delayed surgeries included potentially curative surgeries for kidney cancer – partial and radical nephrectomy. At Rutgers Cancer Institute of New Jersey, surgeries were delayed for one to three months during the pandemic's height in New Jersey.
We wanted to understand the effect of these surgical delays on our patients and their oncologic outcomes. Based on prior studies, it is often accepted that small renal masses (under 4cm) can be safely observed for several months. Our study was particularly interested in larger masses (T1b-T2b), still confined to the kidney. For patients with these tumors, the impact of surgical delay is less understood.
Tell us about the work and what you and your colleagues found?
To study our question, we utilized the National Cancer Database, a large U.S. cancer registry. We examined nearly 30,000 patients with larger, localized kidney cancers and assessed the impact of surgical delay for these patients. We defined surgical delay as time from diagnosis to time of surgery. The oncologic implications of surgical delay in kidney cancer were assessed using two endpoints: pT3a upstaging (local cancer progression) and overall survival.
Patients within each clinical stage were sub-stratified by surgical delay, defined as time from diagnosis to surgery. Surgical delay was categorized as less than one month, one to three months, or more than three months. Cutoffs were chosen based on the authors' clinical experience during the pandemic.
When assessing pT3a upstaging, the study's primary endpoint, upstaging rates within each clinical stage strata were very similar, regardless of surgical delay. In each clinical stage strata – surgical delay did not appear to increase the risk of local tumor progression. Similar results were found when assessing overall survival – it did not appear that surgical delay up to three months correlates to worse survival, even for patients with large localized tumors. Thus, we conclude that surgical delay up to three months does not lead to worse oncologic outcomes.
What are the implications and next steps related to this work?
During the ongoing COVID-19 pandemic, many patients with localized renal cell carcinoma likely experienced surgical delay. Our data may provide reassurance to patients and providers that delays of up to three months likely do not influence cancer outcomes. However, any decision to delay or defer a surgery must take place in the context of the patient comorbidity status, tumor biology and tumor growth kinetics.
Going forward, we must continue to find novel ways to safely care for our kidney cancer population. Furthermore, the long-term direct effects of COVID-19 on cancer patients remains an area for advanced study. As we continue to collect data, we will better understand the direct and indirect effects of the pandemic on the oncology care we deliver.