Department of Urology, Keio University School of Medicine, Tokyo, Japan.
Department of Urology, Keio University School of Medicine, Tokyo, Japan.
Eur Urol Oncol. 2020 Dec;3(6):756-763. doi: 10.1016/j.euo.2019.06.021. Epub 2019 Aug 6.
The current guideline lacks evidence for creating individualized surveillance strategies for upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU).
To create a novel risk model and to simulate individualized surveillance duration that dynamically illustrates the changing risk relationship of UTUC-related death and non-UTUC death, considering the impact of cigarette smoking.
DESIGN, SETTING, AND PARTICIPANTS: This multicenter cohort study comprised 714 pTa-T4N0M0 UTUC patients, with a median follow-up duration of 65mo. There were 279 (39.1%) nonsmokers, 260 (36.4%) current smokers, and 175 (24.5%) ex-smokers.
All patients underwent RNU.
The risks of UTUC death and non-UTUC death over time were estimated using parametric models for time to failure with Weibull distributions. Age-specific, stage-specific, and smoking status-specific surveillance durations were simulated based upon Weibull estimates.
The hazard rate (HR) of non-UTUC death gradually increased over time in all age groups regardless of the smoking status, whereas that of UTUC-related death decreased markedly according to the pathological T (pT) stage and was affected by the smoking status. Among current smokers, the baseline HR of UTUC-related death in pT3/4 was higher than that of pT ≤2 and remained high even 10yr after RNU. Among heavy smokers, the HR of UTUC-related death in all pT stages was highest at baseline and remained high after RNU, compared with nonsmokers, current smokers, or ex-smokers. We simulated specific time points when the risk of non-UTUC death was greater than that of UTUC-related death. Among patients ≥80yr of with pT3N0M0, the risk of non-UTUC death was greater than that of UTUC-related death 1yr after RNU in nonsmokers, but 7yr for heavy smokers.
Our result revealed that smokers bear a long-term risk burden of UTUC-related death more than the risk of non-UTUC death. For UTUC smokers, longer-term surveillance duration is recommended even in elderly stage.
In the present study, we evaluated the risk transition of upper tract urothelial carcinoma (UTUC)-related death and non-cancer-related death over time. We found that smoking weighed a huge impact upon UTUC-related death compared with death from other cause, and therefore, we created a more individualized surveillance duration model.
目前的指南缺乏为根治性肾输尿管切除术（RNU）后上尿路上皮癌（UTUC）患者制定个体化监测策略的证据。
创建一个新的风险模型，并模拟个体化监测持续时间，该模型可以动态说明 UTUC 相关死亡和非 UTUC 死亡的风险关系变化，同时考虑吸烟的影响。
设计、地点和参与者：这项多中心队列研究纳入了 714 例 pTa-T4N0M0UTUC 患者，中位随访时间为 65 个月。其中 279 例（39.1%）为非吸烟者，260 例（36.4%）为当前吸烟者，175 例（24.5%）为戒烟者。
所有患者均接受了 RNU。
使用威布尔分布的时间失效参数模型估计随时间推移的 UTUC 死亡和非 UTUC 死亡风险。根据威布尔估计，模拟了基于年龄、分期和吸烟状态的特定监测持续时间。
无论吸烟状态如何，所有年龄组的非 UTUC 死亡的危险率（HR）随时间逐渐增加，而 UTUC 相关死亡的 HR 则根据病理 T（pT）分期显著下降，并受吸烟状态的影响。在当前吸烟者中，pT3/4 时 UTUC 相关死亡的基线 HR 高于 pT≤2，即使在 RNU 后 10 年仍保持较高水平。在重度吸烟者中，所有 pT 分期的 UTUC 相关死亡的 HR 在基线时最高，并且在 RNU 后仍保持较高水平，与非吸烟者、当前吸烟者或戒烟者相比。我们模拟了非 UTUC 死亡风险大于 UTUC 相关死亡风险的特定时间点。对于≥80 岁且患有 pT3N0M0 的患者，在非吸烟者中，RNU 后 1 年非 UTUC 死亡的风险大于 UTUC 相关死亡的风险，但在重度吸烟者中，这一风险为 7 年。
我们的研究结果表明，与非 UTUC 死亡的风险相比，吸烟者长期承受着 UTUC 相关死亡的风险负担。对于 UTUC 吸烟者，即使在老年期，也建议进行更长时间的监测。
在本研究中，我们评估了 UTUC 相关死亡和非癌症相关死亡随时间的风险转移。我们发现，与其他原因导致的死亡相比，吸烟对 UTUC 相关死亡的影响更大，因此，我们创建了一个更个体化的监测持续时间模型。
