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Treatment utilization and overall survival in patients receiving radical nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma: evaluation of updated treatment guidelines

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Abstract

Purpose

While radical nephroureterectomy (RNU) is the gold standard treatment for upper tract urothelial carcinoma (UTUC), select patients may benefit from endoscopic treatment (ET). European Association of Urology guidelines recommend ET for patients with low-risk (LR) disease: unifocal, < 2 cm, low-grade lesions without local invasion. To inform the utility of ET, we compare the overall survival (OS) of patients receiving ET and RNU using current and previous guidelines of LR disease.

Materials and methods

Patients with non-metastatic, cT1 or less UTUC diagnosed in 2004–2012 were collected from the National Cancer Database. OS was analyzed with inverse probability of treatment weighted Cox proportional hazard regression. Analyses were conducted for LR disease under updated (size < 2 cm) and previous guidelines (size < 1 cm).

Results

Patients who were older, healthier, and treated at an academic facility had higher odds of receiving ET. In 851 identified patients with LR disease, RNU was associated with increased OS compared with ET (p = 0.006); however, there was no difference between ET and RNU (p = 0.79, n = 202) under the previous guidelines (size < 1 cm). In, otherwise, LR patients, the largest tumor size with no difference between ET and RNU was ≤ 1.5 cm (p = 0.07).

Conclusions

RNU is associated with improved survival when compared with ET in the management of LR UTUC using current guidelines with a size threshold of < 2 cm. In appropriately selected LR patients, we find no difference between RNU and ET up to a tumor size of ≤ 1.5 cm. However, in the absence of prospective studies, the usage of ET is best left up to clinician discretion.

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Abbreviations

CSS:

Cancer-specific survival

CDC:

Charlson–Deyo comorbidity

ET:

Endoscopic treatment

EAU:

European Association of Urology

HR:

Hazard ratio

HG:

High grade

IPTW:

Inverse probability of treatment weighted

LG:

Low grade

LR:

Low risk

NCDB:

National Cancer Database

OS:

Overall survival

PFS:

Progression-free survival

RNU:

Radical nephroureterectomy

UTUC:

Upper tract urothelial carcinoma

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Acknowledgements

This work was supported by the National Institutes of Health Loan Repayment Program (L30 CA154326 (Principal Investigator: KC)), the STOP Cancer Foundation (Principal Investigator: KC), and the H & H Lee Surgical Resident Research Award (Recipient: ATL).

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Authors and Affiliations

  1. Department of Urology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Alexander Upfill-Brown, Andrew T. Lenis, Izak Faiena, Amirali H. Salmasi, David C. Johnson, Aydin Pooli, Alexandra Drakaki, Allan J. Pantuck & Karim Chamie

  2. Hematology and Oncology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA

    Alexandra Drakaki

  3. Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA, USA

    Alexandra Drakaki, Allan J. Pantuck & Karim Chamie

  4. Division of Urology, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, USA

    Kiran Gollapudi & Jeremy Blumberg

Authors
  1. Alexander Upfill-Brown
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  2. Andrew T. Lenis
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  3. Izak Faiena
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  4. Amirali H. Salmasi
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  5. David C. Johnson
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  7. Alexandra Drakaki
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  8. Kiran Gollapudi
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  9. Jeremy Blumberg
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  10. Allan J. Pantuck
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  11. Karim Chamie
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Contributions

AUB contributed project design, data analysis, manuscript writing, and editing; AL, project design, manuscript writing, and editing; IF, manuscript editing; AHS, manuscript editing; DCJ, manuscript editing; AP, manuscript editing; AD, manuscript editing; KG, manuscript editing; JB, manuscript editing; AJP, manuscript editing; and KC, project design, manuscript writing, and editing.

Corresponding author

Correspondence to Karim Chamie.

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Conflicts of interest

There are no potential conflicts of interest to disclose.

Informed consent

This research involved an anonymized national patient database and did, therefore, not require informed consent.

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Upfill-Brown, A., Lenis, A.T., Faiena, I. et al. Treatment utilization and overall survival in patients receiving radical nephroureterectomy versus endoscopic management for upper tract urothelial carcinoma: evaluation of updated treatment guidelines. World J Urol 37, 1157–1164 (2019). https://doi.org/10.1007/s00345-018-2506-1

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  • DOI: https://doi.org/10.1007/s00345-018-2506-1

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