Update on kidney cancer screening

How can we improve survival from kidney cancer? “In my opinion, we need to treat high-risk localised diseased better with drugs around the time of surgery, and critically, to detect it earlier,” said Prof. Grant Stewart (GB) while presenting results from the Yorkshire Kidney Screening Trial, as well as future research plans. The latter explored the feasibility of adding abdominal non-contrast CT to screen for kidney cancer and other abdominal pathology to the chest CT offered within lung cancer screening.”

His results illustrated that from the 4,019 who accepted the scan, 5.3% of participants were found to have serious findings involving one or more organ systems. Only 18 participants needed to be screened to detect one serious finding, showcasing the efficiency of this programme. Ninety-three to identify a suspicious renal lesion, and 402 to confirm one case of renal cancer histologically. (Stewart G et al. European Urology, May 2025)

According to Prof. Stewart, the next step is to test whether abdomen screening can stage shift disease and/or improve disease specific survival. Starting this week, this will be evaluated in a randomised trial, piloted first in the ‘live’ Lung Cancer Screening Programme – TACTICAL1 (Targeted Abdominal CT in Conjunction with Lung screen). This feasibility study adds a non-contrast abdominal CT scan to the Targeted Lung Health Check thorax CT in high lung cancer risk ever-smokers aged 55-60 years.

Rehabilitating PSA screening in North America

According to Prof. Laurence Klotz (CA), “The US and Canadian national guidelines are a mess”, both being inconsistent, as well as outdated, with conflicting interests between methodologists and clinicians. In his lecture, he shared details of his work with the ‘Canadian Coalition for Responsible Health Care Guidelines’, a group formed in 2022 to improve guidelines in Canada.

As a result, the Canadian Task Force responsible for writing the guidelines was ‘paused’ by the Ministry of Health this year, with plans to move towards a more agile ‘living guidelines’ approach. Prof. Klotz stressed the importance of involving colleagues from other specialities to ensure expert representation on guidelines panels.

In his opinion, future PCa screening considerations include how to use PSA optimally – specifically, what upper threshold should prompt further testing and what lower threshold to stop testing, including intervals. He recommends a national screening programme for men at risk, restricting testing to only men who will benefit. The outcome will result in less overdiagnosis and morbidity from treatment, as well as fewer biopsies and missed significant cancers.

Whole body-MRI screening for healthy people: A tool for the future?

“Without the right clinical question, even the best technology is useless,” stated Prof. Konrad Stock (DE) as he opened the discussion on the innovative use of whole body MRI (WB-MRI) as a screening tool in healthy people. He emphasised that different cancer types need different strategies for effective detection.

Prof. Giuseppe Petralia (IT) presented on the pros and cons of using WB-MRI as a cancer screening tool in healthy individuals, detailing both its clinical effectiveness and the ethical considerations. He cited findings from his paper on “Oncology relevant findings reporting and data systems (ONCO-RAD): Guidelines for the acquisition, interpretation, and reporting of whole-body MRI for cancer screening.

According to Prof. Petralia, there is no evidence of its cost-effectiveness, raising questions about who pays for it, and who ultimately benefits – such as high-risk groups for cancers that do not currently have screening programmes (e.g., urinary bladder, kidney, pancreas, liver, non-Hodgkin Lymphoma [NHL]).

“The survival benefit of WB-MRI has not yet been measured, but its use is increasing. Studies report up to 99% abnormal findings, with cancer detected in 1-2% of cases. The main challenge is to minimise harm and avoid over-investigation for the majority, while ensuring optimal management for those with confirmed cancer through expert, multi-organ evaluations”.

Prof. Petralia also elaborated on ethical concerns, particularly around the growing direct-to-consumer WB-MRI market, which bypass traditional physician gatekeeping. Their marketing often emphasises potential benefits and minimises limitations. “It is an unregulated industry with no centralised registry or data on companies operating in this space.” He also stated that there are concerns around a truly informed consent from patients.

You can watch the full presentation at the EMUC25 Resource Centre

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FASTRACK II

“Surgery is the standard of care for primary RCC, however older patients might have co-morbidities that may exclude them from this option,” stated radiotherapist Dr. Anna Bruynzeel (NL) in her presentation on the methodology and results of the non-randomised FASTRACK II trial (Focal Ablation Stereotactic Radiotherapy for Cancers of the Kidney). “The aim of the study was to investigate the efficacy of SABR as a treatment option for renal cancer patients who are unwilling or unfit to undergo surgery. This group of RCC patients who are medically inoperable with larger tumours, have limited curative treatment options and need an effective alternative.”

According to Dr. Bruynzeel, SABR is a precise, high-dose radiation treatment targeting tumours with minimal impact on surrounding tissue and the FASTRACK I study concluded this method for primary RCC was feasible and well tolerated. “These findings have been used for the design on this next phase 2 trial.”

Dr. Bruynzeel on the study results: “The medium follow-up was 43 months. For the primary endpoint assessment, local control at 12 months from start of treatment was 100%. There were no local failures observed during the trial. Freedom from distant failure was 97%. Cancer specific survival was also 100%. Overall survival was 99% at 12 months, and 82% at 36 months from the start of treatment.”

“The excellent oncological outcomes after SABR for primary RCC observed in this trial are concordant with those reported in the prospective and retrospective literature. SABR can be considered a proven modality in this group of patients with larger tumours.”

According to Dr. Bruynzeel, the next step is now randomised trial surgery versus SABR. She also concluded her presentation with some remarks to consider: “In comparison to prospective trials of surgery, FASTRACK II has a smaller sample size and less mature follow-up. The study did not have a control group, so it was not possible to access whether SABR is superior, inferior, or similar to other treatment options. Definitions of operability or technically high risk might vary between multidisciplinary teams.”

KEYNOTE 564 OS

Urologist Prof. Jens Bedke (DE) shared the study design and results of KEYNOTE-564 OS that was presented earlier this year at ASCO GU 2024, that indicated this phase 3 trial showed improved overall survival with an adjuvant therapy among patients with clear-cell-renal carcinoma who were at risk of disease reoccurrence after nephrectomy. In his summary, Prof. Bedke stated that pembrolizumab is the first adjuvant treatment in RCC with an improvement in overall survival (OS). In his opinion, there is risk of overtreatment and risk of life-long treatment related adverse events (e.g. life-long toxicities, and life-long L-Thyroxin). “Failure of CheckMate 914, Immotion010 and PROSPER with drugs active in the metastatic setting (nivolumab plus ipilimumab, nivolumab and atezolizumab) raises questions about patient selection and conduct of trials. Better selection criteria using a hybrid of pathological risk, somatic driver mutations and molecular subtypes are required beyond PD-L1 and sarcomatoid features and dosage. New therapy approaches such as mRNA vaccination plus ICI trials are recruiting.”

You can watch a webcast recording of the full RCC Plenary Session on the EMUC24 Resource Centre.

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Mr. Leigh: “We will consider three cases in this session, using the format of an M&M Meeting. We will try to be candid and fair, looking for ways to improve practice. We asked our presenters to choose cases from which lessons may be learned. None of the cases have obvious negligence, but all present learning opportunities.”

A quality audit – measuring outcomes and complications

Asst. Prof. Giorgio Gandaglia (IT) presented a prostate cancer case from his institution for review.

• A 72-year-old male
• BMI 23
• Type 2 DM
• Medication: metformin
• PSA 4.3 ng/ml
• CT scan:  prostate x 1.5, suspicious module right side, prostate 40ml; adenoma 20 ml, prostate biopsy showed adenocarcinoma of the              prostate, FF2, 5/15 positive cores, bone scan was negative, abdominal TC: bilateral renal cysts

The patient underwent a robot-assisted radical prostatectomy. He was discharged on day three postoperative, but on day six, he was admitted to the ER with haematuria and fever, a malfunctioning of the bladder catheter. He was re-admitted to the ER on day 30 with the same complication.

Is it important to chase complications after robotic surgery? According to Asst. Prof. Gandaglia, a wide heterogeneity exists in the rate of postoperative complications after robotic surgery. Although, there has been an exponential increase in the papers using the Clavien-Dondo system over the last few years, only 65% of urologic manuscripts adopt the score correctly.

Asst. Prof. Gandaglia shared details on how his institution learnt from this experience. “The first phase of our prospective study consisted of an audit and feedback process, where the most frequent complications observed in our series were prospectively collected, and in January 2018 an appraisal was done. The most common complication was anastomotic leaks (6.7%). Changes in the surgical technique were proposed to improve outcomes after collegial discussion and review of the surgical videos were recorded during the audit and feedback phase.”

According to Asst. Prof. Gandaglia, the outcome was the introduction of a novel technique for vesico-urethral anastomosis. “The awareness of postoperative outcomes led to the implementation of changes in the surgical techniques that significantly reduced the risk of specific postoperative complications.”

Risks of radical cystectomy

Dr. Carmen Mir (ES) presented a bladder cancer case and how the outcome led to learning and making changes to limit the chance of surgical site infections. She stated that reviewing the risks of radical cystectomy need to cover interoperative, in-hospital, early recovery, and long term. Changes implemented in her institution from this case included fragility assessment for patients over 70 years old, redoes antibiotic therapy and the use of chlorhexidine for prepping. “We also change the surgical instrument set at closure, use running 5mm 1-0 resorbable elastic monofilament, and saline for wound clean up before skin closure”.

A take-home message from Dr. Mir was “Look at your own institution and see what is working and what’s not working. There are a lot of small things that could make a difference to the outcome”.

A need for anticoagulation therapy (ACT) pre-operatively?

Prof. Faiz Mumtas (GB) presented a complicated kidney cancer case of an 80-year-old male with a high BMI of 38 and a visible haematuria with a normal MSU, blood profile and cystoscopy. He had a permanent pacemaker for asymptomatic bradycardia.

According to Prof. Mumtas, in the patients initial CT scan he had a level 2 Pt3b caval tumour. “His staging CT and MRV (Magnetic Resonance Venography) got delayed whilst waiting for a cystoscopy and so he represented with a saddle pulmonary embolism (PE) with an extension in the caval tumour height. With extensive PE we did anticoagulated therapeutically with no significant haemodynamic improvement. Surgery was delayed due to recurrent PE. This further delay led to the growth of the tumour size and it now approached the level of the hepatic veins making it level 3. This indicated a significant progression.”

Prof. Mumtas stated that a cardiac bypass had to be performed at a different institution. He concluded his presentations with the learning points from this case:

1. Anticoagulation in the presence of high-risk factors – recurrent VTE (venous thromboembolism) and bland tumours
2. Concerning up-to-date imaging, Prof. Mumtas suggests no more than a couple of days before surgery.
3. Further multicentre studies are needed to explore the role of pre-operative anticoagulation and neoadjuvant systemic treatments.
4. Operating on level 3 tumours only in facilities where cardiac bypass is available, is to manage patients who become haemodynamically unstable with supra-hepatic clamp.

You can watch a webcast recording of the full presentations on the EMUC23 Resource Centre.

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Dr. Capitanio was upfront about his inexperience on the subject: “I am not a geriatrician but a urologist. Before preparing this presentation, I was not used to assessing the frailty of patients. This is my take, as a urologist, on why frailty is an important factor in RCC, and how it ought to impact our decision-making.”

A small audience survey revealed that a majority had some idea of the definition of frailty, but did not routinely assess the frailty of their patients. This made the talk all the more useful for the urologists and oncologists present.

Definition and implications for treatment

In its broadest sense, Capitanio defined patient frailty as a state of reduced resilience and increased vulnerability and also one in which minor events can trigger disproportionate adverse outcomes. “Frailty is related to, but distinct from ageing, comorbidity and disability.” Capitanio identified two main theoretical concepts of frailty: the frailty phenotype and the accumulation of deficits.

The frailty phenotype is based on five criteria: shrinking (weight loss), weakness (declining grip strength), self-reported fatigue, a decrease in walking speed and self-reported low activity.

The “accumulation” model sees an increase of deficits as people age, with a variety of symptoms collecting in a patient over time. The rate and the deficits will vary between people. The frailty index will count these deficits and generate a score.

There is a variety of ways to establish frailty, some based on measurements. There is also a quicker way that a urologist or oncologist might first identify the characteristics of frailty: “You might be familiar with the Geriatric 8 (G8) screening tool. This survey takes mere minutes to fill out, offering a score between 0 and 17. The EAU PCa Guidelines, for example, use anything below 14 as the cut-off point, requiring a simplified geriatric evaluation.”

Capitanio also pointed to developments in the use of imaging as an objective way to measure frailty. “Cross-sectional imaging can be used to identify lean-muscle cross-sectional surface area in screening for sarcopenia or several skeletal muscle wasting.”

Frailty of the patient has direct implications when it comes to RCC treatment. For instance, frailty means that the toxic effects of treatment are greater, and adverse events are more dangerous. Frail patients may also be less willing to accept the toxic side effects of their treatment.

“A correct evaluation and management can avoid minor events triggering adverse outcomes,” Capitanio concluded. “A baseline evaluation of frailty is mandatory in RCC, especially in elderly patients. Always consider referring the patient to a geriatrician once frailty is identified.”

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