Monday, January 12, 2015

Quality of Life in the Treatment of Clinically-Localized, Small Renal Masses

There are a number of management strategies for patients with clinically-localized, small renal masses (SRM, clinical stage T1) including radical nephrectomy (RN), nephron-sparing surgery (NSS; includes partial nephrectomy, PN, and ablative technologies), and active surveillance. Fortunately survival rates are excellent regardless of treatment [1]. And with recent level I evidence indicating no difference in oncologic or renal-functional outcomes for healthy patients undergoing PN and RN,[2,3] quality-of-life (QOL) is becoming an increasingly important consideration for these patients.

This blog will review what is known regarding QOL in the management of SRM.


Radical Nephrectomy versus Nephron-Sparing Surgery

Most of the studies evaluating QOL in patients undergoing RN and NSS evaluate patients undergoing open surgery (in fact, there are no studies evaluating patients undergoing minimally-invasive PN). In addition, most of these studies employ a cross-sectional survey in which all patients from a given institution were sent a QOL questionnaire at some time period after surgery. Very few studies evaluate patients undergoing surgery in the more ideal, prospective fashion.

Cross-Sectional Studies

It is generally understood that patients undergoing RN and PN are very different patient populations. RN patients are often older, have more comorbidities and larger tumors. Patients undergoing PN are subjected to a higher risk surgery, but have the benefit of preservation of a kidney. 
Despite these differences, a study of the baseline QOL in patients undergoing RN and PN found no difference in general perceived health or QOL among the groups.[4] A more in-depth analysis indicating that patients undergoing PN had better QOL scores related to physical health, while patients undergoing RN had better mental health QOL scores at baseline.
A number of studies indicate that overall QOL is similar following RN and PN.[5-7] The study by Poulakis et al. indicated that patients undergoing PN had higher physical health QOL scores [7], and while the study by Clark et al. did not demonstrate a difference in QOL between RN and PN, those patients with more renal parenchyma (tissue) saved had higher QOL scores.[6] In general, these studies found that while NSS did not predict QOL, comorbidities, tumor size and renal function after surgery related strongly to overall QOL.
In contrast, a study by Ficarra et al. found that patients undergoing PN had improved QOL. Specifically they found lower rates of anxiety and depression in patients undergoing PN; and fewer patients had an impairment of their general health.[8]

Prospective Studies

In a study comparing radio-frequency ablation (RFA) to laparoscopic RN, Onishi et al. found that patients undergoing RFA were older and sicker with resultant lower QOL scores at baseline. However, over the course of six months following surgery, patients undergoing RFA had improvements in QOL while those undergoing RN had a significant detriment to physical functioning, physical health, pain and general health.[9] In the study by Parker et al., patients undergoing RN had improved cancer-related QOL (indicating less fear of cancer recurrence). However, many domains of QOL (including physical health and fear of recurrence) were related to renal function – which was significantly better in patients undergoing PN.[10]


Minimally-Invasive versus Open Surgery

As stated above, most studies evaluate open RN and NSS. Studies evaluating laparoscopic and open surgery indicate that patients undergoing laparoscopic surgery have a quicker return to baseline QOL, but at one year both groups achieve similar QOL.[10] A recent systematic review of this literature indicates that:
  • With regard to RN, laparoscopic surgery has improved perioperative outcomes and related QOL.
  • With regard to NSS, PN results in better preservation of renal function and related QOL regardless of approach. [11]


Active Surveillance and Watchful Waiting

Little QOL data exists in the SRM literature regarding active surveillance (AS) or watchful waiting (WW) programs. Analogous data from prostate cancer AS programs suggest that men do not fare worse in terms of their mental and physical wellbeing compared to those that choose to undergo active intervention [12-15], however there may be increased anxiety, particularly if tumor growth or progression is found.[16]
In a two-year study of patients undergoing WW, greater illness uncertainty was related to poorer general health, cancer-related QOL and higher distress. While physical health-related QOL decreased over the two-year period, intrusive thoughts and avoidance behaviors improved; and mental health-related QOL did not change with time.[17]
In an ongoing prospective study of AS and surgery for SRM, early data indicates that physical health-related QOL is significantly higher at baseline for patients who undergo surgery. While this difference persists throughout follow-up, mental health-related QOL (including depression and anxiety) is not adversely affected for patients undergoing AS over time and when compared to surgery patients.[18]



While there are many shortcomings in the data regarding QOL in the management of SRM, the little data that exists indicates that:
  • There is likely little difference in QOL for healthy patients undergoing RN and PN.
  • A perceived QOL benefit to PN (and other NSS) may be related to preservation of renal function and tissue.
  • While there is no long-term difference in QOL related to open or laparoscopic surgery, patients undergoing laparoscopic surgery may have a quicker return to baseline QOL on average.
  • WW and AS for SRM does not appear to adversely affect mental health-related QOL.


This blog was written by Phillip M. Pierorazio, MD, Assistant Professor of Urology and Oncology.




[1] Patel HD, Kates M, Pierorazio PM, Hyams ES, Gorin MA, Ball MW, Bhayani SB, Hui X, Thompson CB, Allaf ME. Survival after diagnosis of localized T1a kidney cancer: current population-based practice of surgery and nonsurgical management. Urology. 2014 Jan;83(1):126-32. doi: 10.1016/j.urology.2013.08.088. Epub 2013 Nov 16.
[2] Van Poppel H, Da Pozzo L, Albrecht W, Matveev V, Bono A, Borkowski A, Colombel M, Klotz L, Skinner E, Keane T, Marreaud S, Collette S, Sylvester R. A prospective, randomised EORTC intergroup phase 3 study comparing the oncologic outcome of elective nephron-sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol. 2011 Apr;59(4):543-52. doi: 10.1016/j.eururo.2010.12.013. Epub 2010 Dec 22.
[3] Scosyrev E, Messing EM, Sylvester R, Campbell S, Van Poppel H. Renal function after nephron-sparing surgery versus radical nephrectomy: results from EORTC randomized trial 30904. Eur Urol. 2014 Feb;65(2):372-7. doi: 10.1016/j.eururo.2013.06.044. Epub 2013 Jul 2.
[4] Arnold ML, Thiel DD, Diehl N, Wu KJ, Ames S, Parker AS. Comparison of baseline quality of life measures between renal cell carcinoma patients undergoing partial versus radical nephrectomy. BMC Urol. 2013 Oct 22;13:52. doi: 10.1186/1471-2490-13-52.
[5] Clark PE, Schover LR, Uzzo RG, Hafez KS, Rybicki LA, Novick AC. Quality of life and psychological adaptation after surgical treatment for localized renal cell carcinoma: impact of the amount of remaining renal tissue. Urology. 2001 Feb;57(2):252-6.
[6] Gratzke C, Seitz M, Bayrle F, Schlenker B, Bastian PJ, Haseke N, Bader M, Tilki D, Roosen A, Karl A, Reich O, Khoder WY, Wyler S, Stief CG, Staehler M, Bachmann A. Quality of life and perioperative outcomes after retroperitoneoscopic radical nephrectomy (RN), open RN and nephron-sparing surgery in patients with renal cell carcinoma. BJU Int. 2009 Aug;104(4):470-5. doi: 10.1111/j.1464-410X.2009.08439.x. Epub 2009 Feb 23.
[7] Poulakis V, Witzsch U, de Vries R, Moeckel M, Becht E. Quality of life after surgery for localized renal cell carcinoma: comparison between radical nephrectomy and nephron-sparing surgery. Urology. 2003 Nov;62(5):814-20.
[8] Ficarra V, Novella G, Sarti A, Novara G, Galfano A, Cavalleri S, Artibani W. Psycho-social well-being and general health status after surgical treatment for localized renal cell carcinoma. Int Urol Nephrol. 2002-2003;34(4):441-6.
[9] Onishi T, Nishikawa K, Hasegawa Y, Yamada Y, Soga N, Arima K, Yamakado K, Hoshina A, Sugimura Y. Assessment of health-related quality of life after radiofrequency ablation or laparoscopic surgery for small renal cell carcinoma: a prospective study with medical outcomes Study 36-Item Health Survey (SF-36). Jpn J Clin Oncol. 2007 Oct;37(10):750-4. Epub 2007 Oct 17.
[10] Parker PA, Swartz R, Fellman B, Urbauer D, Li Y, Pisters LL, Rosser CJ, Wood CG, Matin SF. Comprehensive assessment of quality of life and psychosocial adjustment in patients with renal tumors undergoing open, laparoscopic and nephron sparing surgery. J Urol. 2012 Mar;187(3):822-6. doi: 10.1016/j.juro.2011.10.151. Epub 2012 Jan 15.
[11] MacLennan S, Imamura M, Lapitan MC, Omar MI, Lam TB, Hilvano-Cabungcal AM, Royle P, Stewart F, MacLennan G, MacLennan SJ, Dahm P, Canfield SE, McClinton S, Griffiths TR, Ljungberg B, N'Dow J; UCAN Systematic Review Reference Group; EAU Renal Cancer Guideline Panel. Systematic review of perioperative and quality-of-life outcomes following surgical management of localised renal cancer. Eur Urol. 2012 Dec;62(6):1097-117. doi: 10.1016/j.eururo.2012.07.028. Epub 2012 Jul 20.
[12] Vasarainen H, Lokman U, Ruutu M, Taari K, Rannikko A. Prostate cancer active surveillance and health-related quality of life: results of the Finnish arm of the prospective trial. BJU international. Jun 2012;109(11):1614-1619.
[13] Wilcox CB, Gilbourd D, Louie-Johnsun M. Anxiety and health-related quality of life (HRQL) in patients undergoing active surveillance of prostate cancer in an Australian centre. BJU international. Mar 2014;113 Suppl 2:64-68.
[14] Daubenmier JJ, Weidner G, Marlin R, et al. Lifestyle and health-related quality of life of men with prostate cancer managed with active surveillance. Urology. Jan 2006;67(1):125-130.
[15] van den Bergh RC, Essink-Bot ML, Roobol MJ, et al. Anxiety and distress during active surveillance for early prostate cancer. Cancer. Sep 1 2009;115(17):3868-3878.
[16] Johansson E, Steineck G, Holmberg L, et al. Long-term quality-of-life outcomes after radical prostatectomy or watchful waiting: the Scandinavian Prostate Cancer Group-4 randomised trial. The lancet oncology. Sep 2011;12(9):891-899.
[17] Parker PA, Alba F, Fellman B, Urbauer DL, Li Y, Karam JA, Tannir N, Jonasch E, Wood CG, Matin SF. Illness uncertainty and quality of life of patients with small renal tumors undergoing watchful waiting: a 2-year prospective study. Eur Urol. 2013 Jun;63(6):1122-7. doi: 10.1016/j.eururo.2013.01.034. Epub 2013 Feb 9.
[18] Pierorazio PM, McKiernan JM, Allaf ME. Quality of Life on Active Surveillance for a Small Renal Masses versus Immediate Intervention: Interim Analysis of the DISSRM (Delayed Intervention And Surveillance For Small Renal Masses) Registry. AUA Annual Meeting, 2013.