Does Partial Nephrectomy Result in a Durable Overall Survival Benefit in the Medicare Population?
Does Partial Nephrectomy Result in a Durable Overall Survival Benefit in the Medicare Population?
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DOI：
10.1016/j.juro.2012.07.099
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发表时间：
2012-12-01
影响因子：
6.6
通讯作者：
Kutikov, Alexander
中科院分区：
文献类型：
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作者：
Smaldone, Marc C.;Egleston, Brian;Kutikov, Alexander
目的：我们评估了部分肾切除术和根治性肾切除术对T1 a肾细胞癌手术患者总体死亡率的影响是否因患者年龄而异。材料和方法：使用链接的SEER（监测、流行病学和最终结果）-医疗保险数据，我们确定了年龄大于66岁的T1 a患者，他们接受了部分肾切除术或根治性肾切除术（4 cm或更小）肾细胞癌，1995年至2007年。使用基于倾向评分的加权调整的时间依赖性考克斯比例风险模型评估手术类型对按年龄划分的总体死亡率的影响。（平均年龄74.2 ± 5.6岁，55.9%为男性）接受肾部分切除术对于4 cm或更小的肾细胞癌（平均肿瘤大小为2.8 ± 0.9 cm），确定了1，665例（30.3%）或根治性肾切除术（3，831例; 69.7%）。校正后，与根治性肾切除术相比，肾部分切除术的1年生存率有统计学意义（年龄68岁，HR 1.6，CI 1.2-2.3;年龄75岁，HR 1.5，CI 1.1-1.9;年龄85岁，HR 1.7，CI 1.1-2.5）和3年（年龄68岁，HR 1.4，CI 1.03-2.0;年龄75岁，HR 1.3，CI 1.1-1.6;年龄85岁，HR 1.5，CI 1.02-2.3），而这些趋势在年龄小于68岁和年龄大于85岁的患者中变得不显著。然而，随着时间的推移，生存率的提高会降低，无论年龄大小，在术后5年和10年，肾部分切除术几乎没有观察到显著的益处（66岁或以上）。由于缺乏长期生存获益的有力证据，老年患者进行肾部分切除术的决定应个体化，并将其置于基线肾功能的背景下，预期手术发病率和生存竞争风险。
Purpose: We assessed whether the impact of partial nephrectomy and radical nephrectomy on overall mortality differed by patient age in a Medicare population undergoing surgery for T1a renal cell carcinoma.Materials and Methods: Using linked SEER (Surveillance, Epidemiology and End Results)-Medicare data, we identified patients older than 66 years who underwent partial nephrectomy or radical nephrectomy for T1a (4 cm or smaller) renal cell carcinoma from 1995 to 2007. The effects of procedure type on overall mortality by age were assessed using time dependent Cox proportional hazards models adjusted by propensity score based weighting.Results: A total of 5,496 patients (mean age 74.2 +/- 5.6 years, 55.9% male) who underwent partial nephrectomy (1,665; 30.3%) or radical nephrectomy (3,831; 69.7%) for 4 cm or smaller renal cell carcinoma (mean tumor size 2.8 +/- 0.9 cm) were identified. After adjustment, a statistically significant survival benefit for partial nephrectomy compared to radical nephrectomy was observed at 1 year (age 68, HR 1.6, CI 1.2-2.3; age 75, HR 1.5, CI 1.1-1.9; age 85, HR 1.7, CI 1.1-2.5) and 3 years (age 68, HR 1.4, CI 1.03-2.0; age 75, HR 1.3, CI 1.1-1.6; age 85, HR 1.5, CI 1.02-2.3), while these trends became insignificant in patients younger than 68 and older than 85 years. However, the survival benefit decreased with time, and little significant benefit with partial nephrectomy was observed at 5 and 10 years after surgery regardless of age (66 years or older).Conclusions: Lacking strong evidence regarding a long-term survival benefit, the decision to perform partial nephrectomy in elderly patients should be individualized, and placed in the context of baseline renal function, expected surgical morbidity and competing risks to survival.