A World-Wide Survey on Kidney Transplantation Practices in Breast Cancer Survivors

The Need for New Management Guidelines

Keith S. Hansen; Hila Ghersin; Merisa Piper; Mehdi Tavakol; Brian Lee; Laura J. Esserman; John P. Roberts; Chris Freise; Nancy L. Ascher; Rita A. Mukhtar

Disclosures

American Journal of Transplantation. 2021;21(9):3014-3020. 

In This Article

Abstract and Introduction

Abstract

Kidney transplantation reduces mortality in patients with end stage renal disease (ESRD). Decisions about performing kidney transplantation in the setting of a prior cancer are challenging, as cancer recurrence in the setting of immunosuppression can result in poor outcomes. For cancer of the breast, rapid advances in molecular characterization have allowed improved prognostication, which is not reflected in current guidelines. We developed a 19-question survey to determine transplant surgeons' knowledge, practice, and attitudes regarding guidelines for kidney transplantation in women with breast cancer. Of the 129 respondents from 32 states and 14 countries, 74.8% felt that current guidelines are inadequate. Surgeons outside the United States (US) were more likely to consider transplantation in a breast cancer patient without a waiting period (p = .017). Within the US, 29.2% of surgeons in the Western region would consider transplantation without a waiting period, versus 3.6% of surgeons in the East (p = .004). Encouragingly, 90.4% of providers surveyed would consider eliminating wait-times for women with a low risk of cancer recurrence based on the accurate prediction of molecular assays. These findings support the need for new guidelines incorporating individualized recurrence risk to improve care of ESRD patients with breast cancer.

Introduction

Transplant surgeons and committees are charged with making organ allocation decisions that not only best utilize a scare resource, but also minimize potential harm in transplant recipients.[1] When potential recipients have co-morbid conditions, such as cancer, these decisions become more complex. Concerns about organ transplantation in the setting of malignancy are largely twofold: first, concern that immunosuppression could hasten or increase the risk of cancer recurrence, and second, that competing risk of mortality from cancer limits the benefit of transplantation.[2] Indeed, large registry studies have shown high rates of cancer recurrence in transplant recipients and various organizations have developed management recommendations for these challenging situations.[3–9]

However, as our understanding of cancer biology increases, so does the ability to more accurately prognosticate recurrence risk and even potentially identify features associated with adverse oncologic outcomes from immunosuppression. This is particularly true in the setting of breast cancer, the most common non-skin malignancy in women and a cancer for which personalized medicine is rapidly becoming possible.[10,11] With this new knowledge comes a need to revisit guidelines and determine current practices for transplantation in this setting.

Breast cancer is increasingly prevalent in patients with end stage renal disease (ESRD) undergoing renal transplant evaluation.[12] Traditionally, transplantation is delayed until cancer remission is proven, with most organizations recommending waiting periods of 2–5 years.[3,10] Given the prevalence of cancer in patients deemed ineligible for kidney transplantation, measuring up to 12% in a study of 409 ESRD patients, existing guidelines have the potential to dramatically impact a patient's access to organs.[13] The heterogeneity of breast cancer is now recognized in its distinct molecular profiles, each of which has varying recurrence patterns.[14] Additionally, molecular tools for predicting response to therapy and recurrence risk are now commonly used in the management of patients with breast cancer.[15,16]

Whether transplant surgeons are aware of these advances in breast cancer management or are using current guidelines for management decisions is unknown. To better understand this, we conducted a web-based international survey study to determine knowledge, practice, and attitudes of transplant surgeons regarding the management of ESRD patients with a history of breast cancer.

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