b'u From Page 19Forpatientswiththehigh-riskcancersingroupmasses are generally biologically indolent, which 3, treatment beyond surgery may be needed. Thatthe surprisingly high rate of aggressive lesions calls could include radiation or other therapies. For uro- into question in the VA population.thelial cell carcinoma, chemotherapy may be recom- In addition, the researchers found that the compli-mended, but neither chemo nor monotherapy withance rate in this study was only 60% and trended targeted therapies have shown benefit in sarcomatoiddownward over time, even with implementation of or papillary RCC. For these aggressive forms of RCCregular reminders by email and phone calls of the and advanced RCC, patients are likely to require thetimingandneedforappointments.Despitethese use of checkpoint inhibitors combined with VEGFR- efforts, follow-up imaging compliance was concern-tyrosine kinase inhibitors (TKI) and may later needingly low at all time points. This is consistent with a multiple receptor TKI combined with an immuneother research showing poor follow-up appointment checkpoint inhibitor.adherenceintheveteranpopulation,theysaid. Therefore, active surveillance may confer unrecog-Small Masses Surprisingly Risky nized risks in our patient population.The Rocky Mountain team drilled down into the data to see whether biopsies of smaller masses, specifi- The Takeawaycally, provided valuable clinical information. AmongIntheVApopulationandunderservedpopula-the masses of 4 cm or less size that were completelytions with limited access to healthcare, or who have within the kidney (T1a), the VA team found that thehigher rates of housing insecurity, toxic exposures, results of the biopsy changed the management plansmoking/alcohol use, etc., I would say more patients in 40 out of 101 cases. Twelve of the others in thisshould be treated rather than be on active surveil-group were excluded from later analysis either be- lance, co-author Kseniya Anishchenko, MD, who cause of nondiagnostic results from biopsy or deter- is now with the University of Pittsburgh Department mination that they were decompressed cysts.of Medicine, told U.S. Medicine. In our VA cohort, Among the masses of 4 cm or less size that werepatients had transportation issues or mistrust of the completely within the kidney (T1a), the team foundmedical system that I think caused follow-up visits that the results of the biopsy changed the manage- to be low.ment plan in 40 out of 101 cases. Twelve of the oth- The study reinforced how important it is for clini-ers in this group were excluded from later analysis,cians [to know] their population and keep societal either because of nondiagnostic results from biopsyfactors in mind when making treatment planssuch or determination that they were decompressed cysts.as looking at the no-show rates of their patients, Of the remaining 89 patients, 12 had benign find- Anishchenko added. It is important to aggressively ings that did not require follow-up. Among the 77treat if you think there are a lot of barriers to a patient with solid masses eligible for follow-up analysis, 56getting healthcare.received cryoablation or underwent surgery and 21Based on the study results, every mass less than 4 chose active surveillance. Half of those who electedcm should be biopsied, she said. In our VA cohort, active surveillance (AS) had oncocytoma or RCCwe found a higher incidence of highly aggressive based on their biopsies.smallmassesthanexpected;knowingthisabout Mostnotably,theteamfoundthat9%ofthesethe VA population means we should biopsy small smaller masses were unexpectedly aggressive vari- masses whenever possible.ants, which differed from previous studies that haveOnereasonthatissoimportantisthatgreatly shown a more indolent course and no difference inimproved treatments for advanced RCC are rapidly overallmortalitybetweenactivesurveillanceandcoming online.primary intervention.Currently,treatmentofadvancedormetastatic The authors noted that, while AS is an effectiverenalcellcarcinomainvolvestargetingthemost managementstrategy,itishighlydependentonrelevantmolecularpathwaysimplicatedincancer patient compliance with follow-up appointments andinitiationandprogression,saidresearchersfrom imaging, as well as the assumption that small renaltheHuntsmanCancerInstituteinSaltLakeCity. 26'