A qualitative framework of non-selection factors for cytoreductive nephrectomy

Purpose Cytoreductive nephrectomy (CN) benefits a subset of patients with metastatic renal cell carcinoma (mRCC), however proper patient selection remains complex and controversial. We aim to characterize urologists’ reasons for not undertaking a CN at a quaternary cancer center. Methods Consecutive patients with mRCC referred to MSKCC urologists for consideration of CN between 2009 and 2019 were included. Baseline clinicopathologic characteristics were used to compare patients selected or rejected for CN. The reasons cited for not operating and the alternative management strategies recommended were extrapolated. Using an iterative thematic analysis, a framework of reasons for rejecting CN was designed. Kaplan–Meier estimates tested for associations between the reasons for not undertaking a CN and overall survival (OS). Results Of 297 patients with biopsy-proven mRCC, 217 (73%) underwent CN and 80 (27%) did not. Median follow-up of patients alive at data cut-off was 27.3 months. Non-operative patients were older ( p = 0.014), had more sites of metastases ( p = 0.008), harbored non-clear cell histology ( p = 0.014) and reduced performance status ( p