Stepan M Esagian, Pavlos Msaouel, Jose A Karam, Benjamin A Gartrell, Dimitrios Makrakis
{"title":"美国转移性肾细胞癌使用减量肾切除术的时间趋势和社会经济决定因素。","authors":"Stepan M Esagian, Pavlos Msaouel, Jose A Karam, Benjamin A Gartrell, Dimitrios Makrakis","doi":"10.1016/j.euf.2025.05.016","DOIUrl":null,"url":null,"abstract":"<p><strong>Background and objective: </strong>The evolving treatment landscape in metastatic renal cell carcinoma (mRCC) since the advent of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) has rendered the role of cytoreductive nephrectomy (CN) unclear. We sought to quantify CN utilization in the USA over the past two decades and assess factors that affect access to CN.</p><p><strong>Methods: </strong>We analyzed the National Inpatient Sample database from 2006 to 2021, identifying mRCC patients who underwent CN using International Classification of Diseases (ICD)-9 and ICD-10 codes. Annual CN utilization rates were calculated and stratified by demographic and socioeconomic factors. Univariable and multivariable logistic regression analyses, guided by directed acyclic graphs, were performed to assess the factors influencing CN utilization.</p><p><strong>Key findings and limitations: </strong>CN utilization declined significantly in 2021 compared with that in 2006 (8.7% vs 15.8%; odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61), a trend observed across all demographic groups. Reduced CN utilization was associated with Black (OR 0.70, 95% CI 0.64-0.76) and Hispanic (OR 0.87, 95% CI 0.80-0.95) race, female gender (OR 0.94, 95% CI 0.90-0.98), Medicare (adjusted OR [aOR] 0.69, 95% CI 0.64-0.73) or Medicaid (aOR 0.59, 95% CI 0.54-0.64) insurance, lower income (aOR 0.84, 95% CI 0.78-0.90), Southern US location (aOR 0.83, 95% CI 0.74-0.93), and treatment at small (aOR 0.57, 95% CI 0.51-0.63) or rural (aOR 0.32, 95% CI 0.26-0.38) hospitals. CN utilization declined further in the ICI (2018-2021) era compared with the TKI era (2006-2017; OR 0.69, 95% CI 0.64-0.75).</p><p><strong>Conclusions and clinical implications: </strong>CN utilization has decreased progressively in the USA, coinciding with the emergence of novel systemic therapies. Several demographic and socioeconomic factors are associated with differential CN utilization. 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We sought to quantify CN utilization in the USA over the past two decades and assess factors that affect access to CN.</p><p><strong>Methods: </strong>We analyzed the National Inpatient Sample database from 2006 to 2021, identifying mRCC patients who underwent CN using International Classification of Diseases (ICD)-9 and ICD-10 codes. Annual CN utilization rates were calculated and stratified by demographic and socioeconomic factors. Univariable and multivariable logistic regression analyses, guided by directed acyclic graphs, were performed to assess the factors influencing CN utilization.</p><p><strong>Key findings and limitations: </strong>CN utilization declined significantly in 2021 compared with that in 2006 (8.7% vs 15.8%; odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61), a trend observed across all demographic groups. Reduced CN utilization was associated with Black (OR 0.70, 95% CI 0.64-0.76) and Hispanic (OR 0.87, 95% CI 0.80-0.95) race, female gender (OR 0.94, 95% CI 0.90-0.98), Medicare (adjusted OR [aOR] 0.69, 95% CI 0.64-0.73) or Medicaid (aOR 0.59, 95% CI 0.54-0.64) insurance, lower income (aOR 0.84, 95% CI 0.78-0.90), Southern US location (aOR 0.83, 95% CI 0.74-0.93), and treatment at small (aOR 0.57, 95% CI 0.51-0.63) or rural (aOR 0.32, 95% CI 0.26-0.38) hospitals. CN utilization declined further in the ICI (2018-2021) era compared with the TKI era (2006-2017; OR 0.69, 95% CI 0.64-0.75).</p><p><strong>Conclusions and clinical implications: </strong>CN utilization has decreased progressively in the USA, coinciding with the emergence of novel systemic therapies. Several demographic and socioeconomic factors are associated with differential CN utilization. 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引用次数: 0
摘要
背景和目的：自从酪氨酸激酶抑制剂（TKIs）和免疫检查点抑制剂（ICIs）出现以来，转移性肾细胞癌（mRCC）的治疗前景不断变化，使得细胞减原性肾切除术（CN）的作用尚不清楚。我们试图量化过去二十年来美国的CN利用率，并评估影响CN获取的因素。方法：我们分析了2006年至2021年的国家住院患者样本数据库，使用国际疾病分类(ICD)-9和ICD-10代码识别接受CN的mRCC患者。根据人口统计和社会经济因素计算CN年利用率并分层。在有向无环图的指导下，进行单变量和多变量logistic回归分析，以评估影响CN利用率的因素。主要发现和局限性：与2006年相比，2021年的CN利用率显著下降（8.7% vs 15.8%；优势比[OR] 0.51, 95%可信区间[CI] 0.42-0.61），这一趋势在所有人口群体中都有观察到。CN利用率降低与黑人（OR 0.70, 95% CI 0.64-0.76）和西班牙裔（OR 0.87, 95% CI 0.80-0.95）种族、女性（OR 0.94, 95% CI 0.90-0.98）、医疗保险（调整OR [aOR] 0.69, 95% CI 0.64-0.73）或医疗补助（aOR 0.59, 95% CI 0.54-0.64）保险、低收入（aOR 0.84, 95% CI 0.78-0.90）、美国南部地区（aOR 0.83, 95% CI 0.74-0.93）、小型医院（aOR 0.57, 95% CI 0.51-0.63）或农村医院（aOR 0.32, 95% CI 0.26-0.38）治疗相关。与TKI时代（2006-2017;OR 0.69, 95% CI 0.64-0.75）相比，ICI时代（2018-2021）的CN利用率进一步下降。结论和临床意义：在美国，随着新型全身疗法的出现，CN的使用率逐渐下降。一些人口统计学和社会经济因素与不同的CN利用率有关。这些发现强调需要进一步研究以阐明CN在不断发展的mRCC治疗前景中的作用。
Temporal Trends and Socioeconomic Determinants of Cytoreductive Nephrectomy Utilization for Metastatic Renal Cell Carcinoma in the USA.
Background and objective: The evolving treatment landscape in metastatic renal cell carcinoma (mRCC) since the advent of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) has rendered the role of cytoreductive nephrectomy (CN) unclear. We sought to quantify CN utilization in the USA over the past two decades and assess factors that affect access to CN.
Methods: We analyzed the National Inpatient Sample database from 2006 to 2021, identifying mRCC patients who underwent CN using International Classification of Diseases (ICD)-9 and ICD-10 codes. Annual CN utilization rates were calculated and stratified by demographic and socioeconomic factors. Univariable and multivariable logistic regression analyses, guided by directed acyclic graphs, were performed to assess the factors influencing CN utilization.
Key findings and limitations: CN utilization declined significantly in 2021 compared with that in 2006 (8.7% vs 15.8%; odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61), a trend observed across all demographic groups. Reduced CN utilization was associated with Black (OR 0.70, 95% CI 0.64-0.76) and Hispanic (OR 0.87, 95% CI 0.80-0.95) race, female gender (OR 0.94, 95% CI 0.90-0.98), Medicare (adjusted OR [aOR] 0.69, 95% CI 0.64-0.73) or Medicaid (aOR 0.59, 95% CI 0.54-0.64) insurance, lower income (aOR 0.84, 95% CI 0.78-0.90), Southern US location (aOR 0.83, 95% CI 0.74-0.93), and treatment at small (aOR 0.57, 95% CI 0.51-0.63) or rural (aOR 0.32, 95% CI 0.26-0.38) hospitals. CN utilization declined further in the ICI (2018-2021) era compared with the TKI era (2006-2017; OR 0.69, 95% CI 0.64-0.75).
Conclusions and clinical implications: CN utilization has decreased progressively in the USA, coinciding with the emergence of novel systemic therapies. Several demographic and socioeconomic factors are associated with differential CN utilization. These findings underscore the need for further research to clarify the role of CN in the evolving mRCC therapeutic landscape.
期刊介绍：
European Urology Focus is a new sister journal to European Urology and an official publication of the European Association of Urology (EAU).
EU Focus will publish original articles, opinion piece editorials and topical reviews on a wide range of urological issues such as oncology, functional urology, reconstructive urology, laparoscopy, robotic surgery, endourology, female urology, andrology, paediatric urology and sexual medicine. The editorial team welcome basic and translational research articles in the field of urological diseases. Authors may be solicited by the Editor directly. All submitted manuscripts will be peer-reviewed by a panel of experts before being considered for publication.
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