Treatment for T1a Renal Cancer Substratified by Size: "Less is More"

Due to the widespread use of computerized tomography, the diagnosis of small renal cancers (3 cm or less) within the T1a classification continues to increase. Current treatment of these tumors includes radical nephrectomy, partial nephrectomy and thermal ablation. We used the SEER (Surveillance, Epidemiology, and End Results) Program to compare treatment modalities for these cancers based on 1 cm increments in tumor size. We examined overall survival, cancer specific survival, survival from cardiovascular disease and race based treatment disparities.

In the SEER database we identified 17,716 renal cancers 3 cm or less diagnosed from 2005 to 2010 treated with radical nephrectomy, partial nephrectomy or thermal ablation. Overall survival, cancer specific survival and cardiovascular survival were determined for each treatment group, and then substratified by size in centimeters, tumor grade, age, geographical location and ethnicity. Survival was analyzed using Kaplan-Meier methods, multivariate proportional hazards models and a propensity score weighted approach.

Overall survival, cancer specific survival and cardiovascular survival were better for partial nephrectomy than radical nephrectomy in all circumstances. Thermal ablation showed equivalent overall survival to partial nephrectomy for tumors 2 cm or less. Notably, radical nephrectomy for renal tumors 3 cm or less was applied in a disparately larger number of black patients (OR 1.63, 95% CI 1.47-1.81) and Hispanic patients (OR 1.28, 95% CI 1.14-1.44).

Radical nephrectomy should be avoided for all tumors 3 cm or less. For renal cancers 2 cm or less partial nephrectomy and thermal ablation are equally effective. For tumors 2.1 to 3 cm partial nephrectomy is better than thermal ablation. We identified significant racial treatment disparities that negatively impact survival in black and Hispanic patients.