Renal cell carcinoma is relatively rare. Approximately 5,000 patients suffer from it in Poland, but this number is constantly increasing. The main problem is the late detection of this cancer. What are the causes and symptoms of kidney cancer, how to diagnose it and what treatment methods are available? - among others, these questions were answered by experts during the Health Policy debate "How is the diagnosis and treatment of kidney cancer changing?".
- The number of Poles diagnosed with kidney cancer has increased from 3,500 to 5,000 patients over the last decade.
- Most renal tumours are detected incidentally, when performing ultrasound examinations for another indication.
- Early diagnosis is important. The majority of cases are detected at an advanced stage of the disease, which often, after treatment, results in recurrence of the cancer.
- The primary method of treatment is surgical treatment. There is a lack of coordination and centralisation of services in Poland, and the pricing of procedures needs to be changed.
- We have access to a drug programme whose criteria limit the doctor's freedom to tailor the therapy to the patient.
The average age of sufferers is around 60 years. Men are more likely to develop the disease than women. Although the causes of kidney cancer are not fully known, obesity, smoking or hypertension and related medication are identified as the main causative factors, although experts point out that this type of cancer can be contracted even with a healthy lifestyle.
Diagnosis from a case
In the majority of patients, a renal tumour is detected incidentally on examination for other reasons. This is usually an ultrasound examination performed when, for example, blood pressure rises.
- In Poland, we achieve 45 per cent five-year survival in all stages of cancer. The European average is around 55 per cent," says National Consultant in Clinical Oncology Professor Maciej Krzakowski. He stresses that early detection of cancer could reduce the number of costly clinical treatments in favour of surgical services, which guarantee better and longer survival.
- In most patients, the tumour is detected when other examinations, i.e. ultrasound, are performed. Less and less detection occurs by identifying the 'textbook triad of symptoms': haematuria, pain and a palpable tumour," says Professor M. Krzakowski.
- At least 95 per cent of kidney cancers in Poland are detected incidentally. Only in every tenth man the reason for the diagnosis is a large tumour, haematuria and pain," points out Jakub Dobruch, MD, PhD, Chairman of the Section of Urology-Oncology of the PTU, Head of the First Department of Urology at the CMKP.
- The main opportunity to improve the situation of patients with kidney cancer is early detection, assessed Deputy Health Minister Maciej Miłkowski. He added that the introduction of ultrasound screening into the package of the preventive screening programme for Poles over 40 years of age is worth considering.
- Ultrasound is a minimally invasive and low-cost test. Using this as part of screening tests performed once every two years from the age of 45 to reduce the proportion of patients with cancer detected at an advanced stage of the disease is one of the directions in which we should be heading, argues Professor Maciej Krzakowski.
– Ultrasound is cheap, has no impact on health and perhaps this method of examination for this, as well as many other conditions, is worth considering, the deputy minister added.
The mainstay of kidney cancer treatment is surgery
- In the last 10 years, we have seen significant progress in systemic treatment. The results of treatment have improved dramatically," assesses Piotr Tomczak, MD, PhD, from the Medical University of Poznań.
- However, we must not forget that, as in most solid tumours, the primary source of cure is surgical treatment. In addition to extensive systemic treatment, we have radical treatment. To date, the standard is that in a patient diagnosed with kidney cancer, the first step is surgical treatment, adds Dr Jakub Dobruch.
- A small renal tumour in a young patient becomes the basis of surgical benefit. This treatment is simple. As far as it is technically possible, a fragment of the kidney should be resected, says Dr Jakub Dobruch, adding that this is a much more difficult operation than resecting the entire kidney. He further emphasises that this service is best performed using laparoscopic technology. - Endoscopic access in lower abdominal surgery carries many benefits for the patient in terms of less discomfort and less chance of complications for the patient, he says.
- However, procedure valuations are not the best. Endoscopic surgery is valued worse than open surgery. Endoscopic surgical technique is not encouraged through funding," assesses Dr Jakub Dobruch.
- Care needs to be taken to centralise complex urology services with an appropriately focused money stream and a focus on quality, equipment and technology going hand in hand with digitalisation, says Dr Jakub Dobruch. - A surgeon who performs such operations five times a year will never achieve mastery, he added.
If not surgical treatment, what kind of treatment?
The drug programme in Poland provides for two lines of treatment (except for a small group of patients for whom a third therapeutic option is also available).
- A total of 10 medicines are available for reimbursement in this indication: 8 chemical substances and two biosimilars," enumerated Deputy Minister Maciej Miłkowski, and added that there is no indication that a new drug will enter the list of reimbursed drugs in this indication in the near future. As he added, at least until March.
- At the moment, the programme has been defined in such a way that the inclusion of new medicinal products - once they are ready for inclusion in the drug programmes - should not significantly increase the cost of the entire programme. Additional substances in the drug programme will only reduce the cost, and current substances will be able to be ordered by doctors at will to meet the patient's needs, the deputy minister argued.
As the experts emphasised, increasing the scope of drug programmes in this indication will not significantly increase the size of the population. However, what is important, more than looking for new drug technologies, is to give physicians the opportunity to target therapies according to the patient's needs, which at this point, experts argued, requires "loosening the rules of eligibility criteria".
- The possibilities at every stage are changing, in renal cancer new targeted therapies, tyrosine kinase inhibitors are appearing quite rapidly. It is difficult to keep up with these innovations," pointed out National Consultant Professor M. Krzakowski. - In the coming years, the available therapeutic options should be rationally enabled to increase access to modern therapies for patients, he argued.
In the opinion of the National Consultant, the first line of treatment, i.e. multi-kinase inhibitors plus, in the unfavourable prognostic group, the m-TOR kinase inhibitor, does not need to be modified. He adds that there could be some modifications in the second line of treatment, which could be agreed in terms of rationality in drug programmes.
- In the coming years, we should ensure wider access to drug technologies already registered in renal cell carcinoma, which would allow doctors to act in accordance with their knowledge and ESMO recommendations, argued Professor Piotr Tomczak. He added that such an action would allow the creation and use of more effective therapies in the longer term, for the benefit of patients.
– Of the 342 calls the 'Gladiator' organisation receives regarding kidney cancer, 58 are from patients diagnosed with advanced stage cancer. However, none of the patients have benefited from the latest generation of therapies. We have modern therapies like immunotherapy or the new generation of tyrosine kinase inhibitors We rarely hear that these therapies have been used. Mainly patients remain in the first and second line of treatment," says Tadeusz Włodarczyk, President of the General Board of the 'Gladiator' Association.
- Patients are of advanced age, have paid taxes and insurance premiums, and pensioners continue to pay health premiums. Why should they seek help abroad? It should be given to them," he added.
Too little investment in prevention
- A lot depends on how we live. There is a great need to reach out to children in schools. According to the WHO, with early education, we are able to avoid half of all cancers. Early awareness to this end is key," argued Dr Jakub Dobruch.
- Patient organisations focus on prevention and education. We run campaigns in various disease entities. In kidney cancer the problems are the same as in other disease entities," says Igor Grzesiak, Board Member of the Foundation Institute for Patient Rights and Health Education.
Together with the President of the General Board of the 'Gladiator' Association, they stated that the main problem is the low funding of educational and preventive activities carried out by NGOs.
source: https://www.politykazdrowotna.com/52104,rak-nerki-jak-zmienia-sie-diagnostyka-i-leczenie