Temporal Trends and Socioeconomic Determinants of Cytoreductive Nephrectomy Utilization for Metastatic Renal Cell Carcinoma in the USA.

Background And Objective: The evolving treatment landscape in metastatic renal cell carcinoma (mRCC) since the advent of tyrosine kinase inhibitors (TKIs) and immune checkpoint inhibitors (ICIs) has rendered the role of cytoreductive nephrectomy (CN) unclear. We sought to quantify CN utilization in the USA over the past two decades and assess factors that affect access to CN.

Methods: We analyzed the National Inpatient Sample database from 2006 to 2021, identifying mRCC patients who underwent CN using International Classification of Diseases (ICD)-9 and ICD-10 codes. Annual CN utilization rates were calculated and stratified by demographic and socioeconomic factors. Univariable and multivariable logistic regression analyses, guided by directed acyclic graphs, were performed to assess the factors influencing CN utilization.

Key Findings And Limitations: CN utilization declined significantly in 2021 compared with that in 2006 (8.7% vs 15.8%; odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42-0.61), a trend observed across all demographic groups. Reduced CN utilization was associated with Black (OR 0.70, 95% CI 0.64-0.76) and Hispanic (OR 0.87, 95% CI 0.80-0.95) race, female gender (OR 0.94, 95% CI 0.90-0.98), Medicare (adjusted OR [aOR] 0.69, 95% CI 0.64-0.73) or Medicaid (aOR 0.59, 95% CI 0.54-0.64) insurance, lower income (aOR 0.84, 95% CI 0.78-0.90), Southern US location (aOR 0.83, 95% CI 0.74-0.93), and treatment at small (aOR 0.57, 95% CI 0.51-0.63) or rural (aOR 0.32, 95% CI 0.26-0.38) hospitals. CN utilization declined further in the ICI (2018-2021) era compared with the TKI era (2006-2017; OR 0.69, 95% CI 0.64-0.75).

Conclusions And Clinical Implications: CN utilization has decreased progressively in the USA, coinciding with the emergence of novel systemic therapies. Several demographic and socioeconomic factors are associated with differential CN utilization. These findings underscore the need for further research to clarify the role of CN in the evolving mRCC therapeutic landscape.