Malignancy screening in ESRD patients

Dr. Weal Habhab,MD,FRCPCNephrology Consultant

Nephrology Section HeadKing Faisal Specialist Hospital -Jeddah

eGFR and risk of cancer death

Risk of cancer in ESRD Controversial, but it is reported to be higher in

ESRD compare to general population Lancet,1999: international study indicated the

standardized incidence ratio(SIR) of cancer to be 1.18 higher in ESRD patients.

NDT,2011: study from Taiwan showed the SIR to be 1.4 in 4328 patients in 4.4 years follow up study.

Observations The risk was higher in

o Younger patients <35

o Female patients

o In the first year of dialysis

The over all risk of cancer

Number of new cancer cases SIR 95% CI

All patients 4328 1.4 1.3–1.4    Male 2069 1.2 1.1–1.3    Female 2259 1.6 1.5–1.7Age at first dialysis

    0–34 years 129 9.2 5.3–16.0

    35–54 years 1433 3.5 3.1–3.9

    55–65 years 1180 1.7 1.6–1.9

    ≥65 years 1586 0.8 0.7–0.8

Time after first dialysis

    Year 1 723 8.3 7.6–9.0    Year 2 735 3.9 3.6–4.2    Year 3 672 2.9 2.7–3.1    Year 4 581 2.0 1.9–2.2    Year 5 467 1.6 1.5–1.8    Years 6–8 822 1.0 0.9–1.1    >Year 8 328 0.3 0.2–0.3

Predisposing factors Acquired renal cystic disease

Medication , CYP

Infections, HBV and HCV

Human papilloma virus

Mechanism Controversial :

o Infections

o Prolonged chronic uremia impair T-cells and APC functions

o Nutritional abnormality like Vit D deficiency and selenium deficiency

Top cancer in ESRD Bladder Kidney Liver Cervix Tounge

Prognosis USRDS 2007, showed the risk of death from

cancer among ESRD to be 7 deaths per 1000 patients.

While cardiac arrest resulted in 38 deaths per 1000 patients at the same period.

Screening of cancer among ESRD patients

Benefits

High mortality from non-malignant causes

Screening One study examined the benefits of

mammography, PSA, sigmodiscopy and pap smear as screening tools among ESRD and showed ,o The costs per unit of survival benefit conferred by cancer

screening were 1.6 to 19.3 times greater among patients with ESRD compared with the general population

o The net gain of life expectancy in patients with ESRD via these screening programs was calculated to be five days or less. Similar survival gains could be obtained by reducing the baseline ESRD mortality rate by 0.02 percent.

Screening tests routine cancer screening in the ESRD population

did not represent an efficient allocation of financial resources

Similar findings were reported in a study evaluating the efficacy of breast and cervical cancer screening of Canadian women undergoing maintenance dialysis.

Screening tests Colorectal cancer:In one series, the incidence of guaiac positive stools was three times higher in asymptomatic dialysis patients compared with non-ESRD controls .

Nevertheless, the presence of a positive stool guaiac test in an asymptomatic individual with ESRD may permit the early discovery of a colorectal malignancy .

Screening test Prostate cancer

o Screening with PSA still controversial in general population.

o A higher incidence of prostate cancer among patients with ESRD has been reported .

o Serum PSA levels do not appear to be affected by renal failure

.o But it is not cost effective except in pretransplant

evaluation

Screening test Cervical cancer

o The standardized incidence ratio of cervical cancer among

ESRD patients is approximately 2.5 to 4 times that in the normal population o This higher risk is due primarily to the increased

presence of the human papilloma virus (HPV) in this patient population.

Cervical cancero Pap smear screening beginning at age 21 years of age

o HPV DNA testing and HPV vaccine, especially in transplant candidates

o Yearly Pap test in those on transplant waiting lists and in

patients with risk factors and long expected survival based on demographic factors and comorbid conditions affecting survival in ESRD.

Screening tests Breast cancer

o Yearly mammograms and breast examinations for women >40 years of age and on transplant waiting lists would be reasonable.

Screening tests Renal cell carcinoma Acquired cystic disease is premalignant condition The incidence is 22% in patient on maintenance

dialysis The incidence of RCC as complication of acquired

cystic disease varies between 2-4% yearly screening for acquired cystic disease with

US to be performed in patients who have been on dialysis for three to five years

Screening tests Tumor markers:

o The accuracy of other tumor markers in ESRD patients is unknown.

o They are of high molecular weight and ineffectively removed by dialysis, giving highly false positive rate.

o Still alpha- fetoprotein ,PSA of high value

Summery Practice guidelines and/or standards for cancer

screening that have been developed in the general population are not necessarily applicable to patients with end-stage renal disease (ESRD).

Cancer screening protocols are best implemented on an individual patient basis.

Special consideration should be given to patients on transplant list

Routine cancer screening is perhaps most inappropriate in patients with ESRD who are diabetic, white, or ≥65 years of age.

Thank you