A path for diagnosis, therapy, follow up and research of kidney cancer: our experience in kidney cancer management
Kidney cancer is one of the top ten most common cancers (1). Many renal masses remain asymptomatic until the late stages of the disease (2). As a consequence more than 50% of kidney cancers are detected incidentally. Otherwise it can be detected in an advanced stage when the patient reach an emergency department with a massive hemorrhage, flank pain, gross haematuria, or general decadency (3). A multidisciplinary approach seems particularly useful for patients with malignancy of kidney (4).
PDTA is a path of diagnosis, therapy, follow up and research of patients (pts) with kidney cancer, based on a multidisciplinary approach in order to have the highest quality of patient care.
Our aim is to improve and make more easily accessible path to the person facing the disease, and to improve patient satisfaction regarding the relationship with the hospital.
Materials and Methods
All patients who come to our hospital, with suspect or certain kidney cancer are evaluated in a specific multidisciplinary path.
Protocols of diagnosis, staging, surgical or medical treatment and follow-up are defined. Indicators of process and result have been identified and will be periodically verified in order to evaluate the implementation of the path and the improvement of patient care. The main indicators are summarized below:
– median time between access to the hospital and starting medical treatment or
– hospitalization rate in emergency for suspected kidney cancer
– ratio between number of pts who have suspended or interrupted drug therapy
autonomously and number of pts treated
– IP1: time between the date of the radiological findings of localized renal mass and
– IP2-IP3: time between the date of the radiological findings of metastatic disease
and cytoreductive surgery or medical treatment
– IR1-2: time to recurrence after radical or conservative surgery
– IR3: % overall survival (OS)
– IR4-IR5: % G3 or G4 toxicity (CTCAE=Common Terminology Criteria for Adverse Events)
– IR6-IR7: time to disease progression during 1° or 2° line treatment
– IR8: % of OS after starting of medical treatment
– IA1: % adherence to guidelines
– IA2: % pts evaluated by the multidisciplinary team
The degree of satisfaction of the patient is evaluated through a questionnaire and results will allow us to improve the path.
From November 2014 to December 2015, 94 patients were included in the path. The main
– Median age: 60 years old;
– Median time between access to the hospital and starting medical treatment or
surgery: 32 days and 48 days, respectively;
– Rate of hospitalization in emergency for suspected kidney cancer: 56%;
– Metastatic disease at the time of diagnosis: 22%;
– Patients who underwent renal surgery as first therapeutic step: 13%;
– Patients who underwent nephron-sparing surgery: 43%;
– Patients who underwent radical surgery: 57%;
– Ratio between number of patients who have suspended or interrupted drug therapy
autonomously and number of patients treated: 10/94.
It is still too early to collect data on recurrence and survival.
In the last year we have experienced a growth in the number of patients who have reached our hospital for diagnosis and treatment of kidney cancer of 15%. As a consequence, actually the median time between access to the hospital and starting medical treatment or surgery was slightly higher than the previous year (30 days in September 2014 versus 32 days in December 2015 for medical treatment, 46 days in September 2014 versus 48 days in December 2015 for surgery). The rate of patients who underwent hospitalization at our emergency department with the unique aim to achieve a diagnosis of kidney cancer was 95% in the 2014. With a multidisciplinary approach to kidney cancer we have reduced this rate from 95% to 56%. In the future, our aim will be to reduce the median time of access to medical and surgical cure also if we expect a progressive growth of patients who will reach our hospital for the diagnosis and for the therapy of kidney cancer. Another target will be to reduce the rate of patients who underwent hospitalization at our emergency department with the unique aim to achieve a diagnosis of kidney cancer. Last but not least another target will be to reduce the number of patients who autonomously interrupt drug therapy improving the monitoring of drug adverse events and providing more information to the patients about the management of drug adverse events.
Our experience of creation of PDTA with the detection of indicators of process and result to monitor the path and a periodic activity of clinical audit may become an important tool to ensure quality care. Overall, we have experienced a growth in the number of patients who have reached our hospital and we have reduced the rate of patients who underwent hospitalization at our emergency department with the unique aim to achieve a diagnosis of kidney cancer. In December 2014, we received the certification of excellence IS0 9001-2008 for diagnosis, treatment and research of kidney cancer through a multidisciplinary approach and in December 2015 the certification has been confirmed.
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4- Pelikaan L, Vriesema JL, Brusse-Keizer MG, Cornel EB Value of a multidisciplinary team for patients with a urological malignancy. Ned Tijdschr Geneeskd. 2015;159:A8590.Argomenti: cancro del rene