Tailored Screening for Urinary System Cancers in Patients with Chronic Kidney Disease

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Project Summary Chronic kidney disease (CKD) is a highly prevalent condition, found in 20% of people aged 50 years and older. While it is well known that CKD is strongly associated with cardiovascular mortality, recent work has demonstrated an association with cancer risk that also merits consideration for preventive strategies. Cancer is the leading cause of death in mid-life patients afflicted by early stages of CKD, and the 2nd leading cause across all CKD patients under 65 years. Specifically, kidney cancers occur three times more often in patients with CKD, including a hazard ratio of up to 3.4 in younger men (40-52 years) with moderate CKD (15-60 mL/min/1.73 m2). Indeed, the incidence of kidney cancer in mid-life patients with CKD is similar to that of colorectal cancer in the general population. Risks of bladder cancer are similarly increased in CKD. Current guidelines recommend that CKD patients undergo monitoring of common renal and cardiovascular risk factors that overlap with those of urinary tract cancers such as smoking, hypertension, and obesity. Thus, the lack of clear cancer screening recommendations represents an important gap in CKD practice guidelines, and may be due to the complex weighing of benefits and harms for a population with wide-ranging health status. Our team of experts in decision science, epidemiology, urologic oncology, nephrology, radiology, and internal medicine will apply complementary experience to assess the potential of screening strategies. We previously developed and published a computer simulation model of kidney tumors and comorbidities, supported by an NCI K award, the Renal Anatomy and Function for Renal Masses (Re-AFFiRM) simulation model. Our model is capable of simulating outcomes of subpopulations defined by CKD severity and kidney tumor natural history. We will transform the model to incorporate bladder cancer natural history as well as kidney and bladder screening pathways. We will assess whether cancer screening pathways benefit life expectancy and quality-adjusted life expectancy based on age, CKD stage, strong co-existing risk factors, and comorbidity burden. Middle-aged adults without other significant cardiovascular comorbidity and multiple established risk factors may warrant more intensive screening, whereas patients with cardiovascular disease and few risk factors may warrant less intensive screening. In addition, Black men and women with CKD have been shown repeatedly to suffer higher all-cause and cancer-specific mortality compared to non-Black CKD patients, an important consideration in forming screening recommendations. Our findings will be evaluated by a group of independent stakeholders in primary care, nephrology, urology, and patient advocacy to consider the acceptability and barriers to screening as supported by the model results. Cost-effectiveness will also be explored for key factors that affect or elevate the value of screening. Our goal will be to establish the context in which urinary tract screening recommendations could benefit the large population with CKD.