Advances in Rehabilitation Medicine

Renal cell carcinoma is estimated to be the eighth most common cancer in the United States as of 2021, with 70 percent of cases presenting as localized renal cancer. When diagnosed at an early stage, renal cell carcinoma carries a favorable prognosis, with five-year survival rates over 90 percent. Previously, the standard of care for localized renal masses was open radical nephrectomy but today improvements in surgical techniques and minimally invasive approaches have led to a move to partial nephrectomy as the preferred treatment when feasible. This approach provides similar oncological outcomes to radical nephrectomy but carries a lower risk of chronic kidney disease.

It has been found that many of the patients who are eligible to receive partial nephrectomy but instead receive radical nephrectomy are disproportionately people of color and patients with low socioeconomic status (SES). Black patients are more likely to receive radical nephrectomy as compared to White patients, particularly in cases of T1a disease, which is especially disturbing given their higher rates of hypertension and diabetes. Studies have also shown that partial nephrectomy is used more often for patients with higher education levels living in higher income communities.

Dr. Christopher Anderson

Brendan Wallace, Medical Student

In a recent study, Christopher B. Anderson, MD, MPH, a urologic oncologist in the Department of Urology at NewYork-Presbyterian/Columbia University Irving Medical Center, and Brendan K. Wallace, Columbia medical student and first author on the study, tested the hypothesis that the effect of increased socioeconomic status on the surgical management of localized renal masses would not be the same for Black and White patients in New York City. Dr. Anderson, along with colleagues in Columbia’s Department of Biostatistics, chose to focus on New York City for this study as it is among the most diverse cities in the country with both the poorest and wealthiest residents.

The Columbia researchers drew on the New York State Cancer Registry (NYSPACED) database, identifying 5,633 patients aged 20 or older with a localized renal mass between 2004 and 2016. Localized masses were defined through the Surveillance, Epidemiology, and End Results (SEER) Summary Stage system. Patients were segmented as having received partial or radical nephrectomy. They applied logistic regression to determine the association of race and socioeconomic status on receipt of partial nephrectomy controlling for age, ethnicity, gender, and year of diagnosis.

Results of the study, which were published in the February 2022 issue of Urologic Oncology, showed:

• Utilization of partial nephrectomy increased for both Black and White patients over time.
• Patients from the higher socioeconomic status quartiles were more likely to receive partial nephrectomy as compared to the lower quartiles.
• Compared to White patients, Black patients were less likely to receive partial nephrectomy.
• As socioeconomic status increased, White patients had an increase in receipt of partial nephrectomy, an association the researchers did not observe for Black patients.

The Columbia investigators noted that research has shown that physician treatment recommendations differ according to race even when adjusting for income, particularly for treatments that involve a greater degree of physician discretion, such as in renal transplantation. Further, elderly White patients are more likely to purchase private insurance in addition to their Medicare coverage to pay for higher out-of-pocket medical expenses. Given that Black patients generally have markedly lower wealth than White patients at the same income level, these additional expenses may represent an obstacle to optimal care.

Though the researchers did not know the treating hospitals for the patients in their cohort,
the difference in treatment by race for patients from high SES communities may be clarified by geography. Manhattan offers the highest number of National Cancer Institute-Designated Cancer Centers in New York City, and such hospitals are associated with greater use of partial nephrectomy. While Black and White patients within the lowest SES quartile lived in areas somewhat equal in distance from Manhattan, White patients from the highest SES quartile were more likely to live in Manhattan itself.

The Columbia authors concluded, “This association was modified by race, such that White patients were significantly more likely to receive partial nephrectomy as neighborhood SES quartile increased, whereas Black patients were not.”