An Analysis of Staging and Treatment Trends for Upper Tract Urothelial Carcinoma in the National Cancer Database

Kidney-sparing surgery for upper tract urothelial carcinoma (UTUC) has recently shown good outcomes for low-risk patients in lieu of nephroureterectomy. We used the National Cancer Database to analyze trends in practice patterns for UTUC. Use of ureteroscopic biopsy and laser ablation has increased over the past decade with decreases in nephroureterectomy as clinicians increasingly use these techniques. Background: The purpose of this study was to analyze contemporary trends for diagnosis and treatment of upper tract urothelial carcinoma (UTUC). Patients and Methods: We identified all cases of UTUC in the National Cancer Database (NCDB) between 2004 and 2013. Data comprising tumor, patient, and facility factors were extracted. Treatment data for surgery and chemotherapy were also collected. Comparisons used chi(2) testing. Results: Over this 10-year period, the sex and age distribution of UTUC was stable at 60% male and median age of 72 years. Most tumors were < cT2 at diagnosis, with an upward trend over 10 years (66% to 72%; P < .001). However, presentation with clinical metastatic disease also rose, from 4.6% to 8.9% (P < .001). Primary tumor biopsy increased from 37% to 50%. Overall rate of nephroureterectomy decreased from 59.6% to 56.7% whereas endoscopic ablation increased from 9.8% to 11.5%. Ablation was much more common in < cT2 tumors than >= cT2 (18.3% vs. 3.7%) and for lowgrade tumors than high-grade (22.6% vs. 5.9%). Neoadjuvant chemotherapy was significantly more used, but still at a low rate. Conclusion: Treatment of UTUC appears to be shifting toward conservative surgical management with tumor ablation, and increasing neoadjuvant chemotherapy use. More primary tumor biopsies are being performed, likely reflecting improved ureteroscopic instruments and training. The NCDB also reports an increase in metastatic disease, which must be interpreted cautiously and might be artifactual.