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Current evidence on screening for renal cancer

Abstract

Renal cell carcinoma (RCC) incidence is increasing worldwide. A high proportion of individuals are asymptomatic at diagnosis, but RCC has a high mortality rate. These facts suggest that RCC meets some of the criteria for screening, and a new analysis shows that screening for RCC could potentially be cost-effective. Targeted screening of high-risk individuals is likely to be the most cost-effective strategy to maximize the benefits and reduce the harms of screening. However, the size of the benefit of earlier initiation of treatment and the overall cost-effectiveness of screening remains uncertain. The optimal screening modality and target population is also unclear, and uncertainties exist regarding the specification and implementation of a screening programme. Before moving to a fully powered trial of screening, future work should focus on the following: developing and validating accurate risk prediction models; developing non-invasive methods of early RCC detection; establishing the feasibility, public acceptability and potential uptake of screening; establishing the prevalence of RCC and stage distribution of RCC detected by screening; and evaluating the potential harms of screening, including the impact on quality of life, overdiagnosis and over-treatment.

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Acknowledgements

The work of J.U.S., G.D.S. and S.H.R. on screening in RCC is funded by a research grant from Kidney Cancer UK. J.U.S. is supported by a Cancer Research UK Cancer Prevention Fellowship (C55650/A21464). G.D.S. is supported by Cancer Research UK Cambridge Cancer Centre (Major Centre Award A25117). S.H.R. is supported by The Urology Foundation, the Renal Cancer Research Fund and a Cancer Research UK Clinical Research Fellowship. We thank patient representatives Philip Dondi and Phil Alsop for their helpful comments on this paper.

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R.K.S. wrote the manuscript and all authors provided a substantial contribution to the discussion of content and reviewed and/or edited the article before submission.

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Correspondence to Grant D. Stewart.

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Competing interests

G.D.S. has received educational grants from Pfizer, AstraZeneca and Intuitive Surgical; consultancy fees from Pfizer, Merck, EUSA Pharma and CMR Surgical; travel expenses from Pfizer and speaker fees from Pfizer. R.K.S. is the Chair of the International Advisory Board for the Danish Diabetes Academy, which is funded by the Novo Nordisk Foundation. The other authors declare no competing interests.

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Supplementary information

Glossary

Allocation bias

Overestimation of mortality rates in registry data owing to increasing numbers of individuals diagnosed with disease and therefore ‘eligible’ to die with the disease over time.

Lead-time bias

Overestimation of survival duration owing to screening detecting disease earlier (during the asymptomatic phase), meaning individuals with screen-detected cancer appear to live longer simply owing to earlier diagnosis (rather than a true improvement in survival).

Length-time bias

Overestimation of survival owing to screening detecting more slowly progressive and less aggressive disease in asymptomatic individuals whereas individuals with more aggressive disease are more likely to be diagnosed outside a screening programme owing to symptoms.

Treatment disconnect

The paradoxical rise in overall and cancer-specific mortality despite increased detection and treatment of renal cell carcinoma.

Value of information analysis

In health economic evaluations, decisions regarding whether to adopt an intervention are taken in the context of uncertainty; the value of information analysis assesses the value of additional evidence to reduce decision uncertainty, suggesting whether further research into this topic might be a good use of resources.

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Usher-Smith, J., Simmons, R.K., Rossi, S.H. et al. Current evidence on screening for renal cancer. Nat Rev Urol 17, 637–642 (2020). https://doi.org/10.1038/s41585-020-0363-3

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