News in Brief

Women vs Men Less Likely to Receive Guideline-Based Kidney Cancer Care

They had lower odds of undertreatment and higher odds of overtreatment

WOMEN ARE MORE likely than men and Blacks and Hispanics are more likely than Whites to receive kidney cancer treatments that deviate from accepted clinical guidelines, according to a recent study.

Compared with men, women had significant 18% lower odds of undertreatment and 27% higher odds of overtreatment in adjusted analyses, Jeffrey M. Howard, MD, PhD, of the University of Texas Southwestern Medical Center in Dallas, and colleagues reported in JAMA Network Open.

“One might question whether there are underlying clinician-driven or patient-driven reasons for this disparity,” the investigators wrote. “For example, there may be a tendency of clinicians to perceive female patients as having greater potential longevity and therefore warranting more aggressive cancer treatment. Alternately or concurrently, there may be a systematic preference among female patients for more aggressive treatment.”

Compared with White patients, Black and Hispanic patients had significant 42% and 20% increased odds of undertreatment, respectively, and 9% and 6% higher odds of overtreatment.

In addition, patients who were uninsured had significant 2.6-fold higher adjusted odds of undertreatment and 28% lower odds of overtreatment compared with insured patients.

“We found that female patients had higher odds of receiving more aggressive treatment than men, which was associated with increased rates of overtreatment for small kidney masses and potentially increased risk for unjustified complications,” Dr Howard and colleagues concluded. “Black race and Hispanic ethnicity were associated with higher odds of undertreatment and overtreatment, highlighting the bidirectional nature of inequities in treatment.”

Using 2010-2017 data from the National Cancer Database, the investigators studied 158,445 patients treated for localized kidney cancer, of whom 99,563 (62.8%) were men, 120,001 (75.7%) were White, and 91,218 (57.6%) had private insurance.

Of the study cohort, 3893 patients (2.5%) were undertreated and 44,651 (28.2%) were overtreated.

Dr Howard and colleagues assigned patients to 1 of 4 tumor classifications based on tumor size and clinical stage and categorized patients as receiving guideline-based treatment or under- or overtreatment. For tumors less than 2 cm in diameter, guideline-based treatment would be surveillance and overtreatment would be ablation or partial or radical nephrectomy. For tumors 2-4 cm in diameter, guideline-based treatment would be surveillance, ablation, or partial nephrectomy, and overtreatment would be radical nephrectomy. For tumors 4-7 cm and larger than 7 cm, partial or radical nephrectomy would be guideline-based treatment and surveillance or ablation would be undertreatment. ■

Uninsured vs insured patients had 2.6-fold higher adjusted odds of undertreatment.

Hospitalization Pattern May Predict ESKD Risk

PATIENTS WITH CHRONIC kidney disease (CKD) who are more frequently hospitalized are more likely progress to end-stage kidney disease (ESKD) or die compared with patients who are rarely hospitalized, independent of traditional risk factors, a new study finds.

Among 3012 individuals with CKD stages 2 to 4 in the Chronic Renal Insufficiency Cohort (CRIC) study, 5658 hospitalizations occurred within 4 years. The high-, intermediate-, and low-utilizer groups had a mean 6.3, 2.2, and 0 all-cause hospitalizations, respectively, over the period, Anand Srivastava, MD, MPH, of Northwestern University Feinberg School of Medicine in Chicago, Illinois, and colleagues reported in Kidney International Reports. For both high and intermediate utilizers, the top 5 reasons for hospitalization were circulatory system disorders, infectious diseases, endocrine disorders, musculoskeletal system disorders, and injury and poisoning. High utilizers had a significantly longer hospital stay compared with intermediate and low utilizers: 1.6 vs 0.5 vs 0 days, respectively, according to the investigators.

After the 4 year period, 544 ESKD events and 437 ESKD-censored deaths occurred during a median follow-up duration of 5.1 years. In adjusted analyses, intermediate and high utilizers had a 1.5- and 1.8-fold higher risk of ESKD, respectively, compared with low utilizers, Dr Srivastava’s team reported. Intermediate and high utilizers also had a 1.5- and 2.6-fold higher risk of ESKD-censored death, respectively.

Intermediate and high utilizers were more likely than low utilizers to be female and Black and have lower income, diabetes, cardiovascular disease, lower serum albumin, lower hemoglobin, higher body mass index, proteinuria, and lower estimated glomerular filtration rate.

“Collectively, our results suggest that trajectories of cumulative all-cause hospitalization identify high-risk individuals with CKD who have rapidly declining health, as suggested by their need for increased health care resource utilization,” Dr Srivastava and colleagues wrote. They suggested that hospitalization trajectories could be a simple severity of illness marker that treating physicians could review in a patient’s electronic medical record.

In an accompanying editorial, Stuart L. Goldstein, MD, of the Center for Acute Care Nephrology, Cincinnati Children’s Hospital, University of Cincinnati College of Medicine in Cincinnati, Ohio, wrote, “Finally, and obviously, our goal should be to slow CKD progression and reduce mortality risk. The utilization groups not only identify patients who may require more clinical attention but can enrich the CKD population to direct novel interventions to the most at-risk patient.” ■

Customized PCa Ablation Is Feasible

CUSTOMIZED prostate ablation with magnetic resonance imaging (MRI)guided transurethral ultrasound ablation (TULSA) offers “favorable and promising” early MRI and PSA results for men with prostate cancer (PCa), according to study findings published in Urologic Oncology.

The procedure is a feasible combination therapy for patients who have PCa and concurrent benign prostatic hyperplasia (BPH), they concluded.

“This first real-world series of customized prostate ablation using TULSA demonstrated the safety and early efficacy of partial through wholegland ablation in men with low- to highrisk localized prostate cancer, as well as symptom relief in men with concurrent cancer and BPH,” a team led by Rolf Muschter, MD, of ALTA Klinic in Bielefeld, Germany, concluded.

The investigators studied 52 consecutive patients with localized PCa who underwent TULSA. Of these, 47 had not previously received treatment and 5 underwent salvage therapy for recurrent PCa. Of the 52 patients, 41 (78.8%) underwent partial ablation, whereas the remainder received whole-gland ablation.

The investigators said they customized ablation volume based on various factors, including location and Gleason score of the primary lesion, presence of secondary lesions, a diagnosis of BPH, and patient preference.

Both PCa and BPH were present in 23 patients in the treatment-naïve group and 1 patient in the salvage therapy group.

The median follow-up duration was 16 months. The early treatment success rate, defined as negative multiparametric MRI findings and lack of PSA recurrence, was 88%, Dr Muschter and colleagues reported. The median PSA level following primary treatment was 1.1 ng/mL. A single repeat TULSA was performed in 9 patients. All 37 patients who were potent prior to TULSA maintained potency. Of the patients who also had BPH, 83% reported improvement in symptoms. ■