Editorial Comment: Racial and Ethnic Disparities in the Utilization of Partial Nephrectomy and Robotic Surgery for Renal Cell Carcinoma

This analysis by Puente et al represents a timely and relevant analysis of racial and ethnic disparities in the treatment of clinical stage 1 to 2 renal cell carcinoma (RCC), including differences in surgical approach (robotic vs open) and nephron-sparing surgery (partial nephrectomy [PN] vs radical nephrectomy [RN]). A cohort of 122,920 patients, spanning a decade of treatment, was analyzed from the National Cancer Database.1 They demonstrate persistent racial and ethnic disparities in applying guideline-concordant surgical care for RCC. Hispanic and non-Hispanic Black (NHB) patients had lower odds of undergoing robot-assisted procedures for cT1a and cT1b tumors compared with non-Hispanic White patients. Both groups had reduced likelihood of undergoing PN for cT1a masses. Interestingly, NHB patients exhibited higher odds of receiving PN for larger tumors (cT1b or cT2). Temporal analysis showed that the gap for receipt of PN and RN between these groups has narrowed with concurrent expansion in PN for all stages and ethnicities.1 These findings should be interpreted in the context of accumulating evidence that treatment at high-volume centers most strongly predicts PN or robot-assisted surgery.2 Improving equity in RCC management is a multifactorial project. Regionalization of RCC surgery coupled with telemedicine and local partnerships for postoperative surveillance may be one facet. Financial and quality-of-life toxicities associated with regionalization, such as longer waits and travel times, must be considered before implementation of this strategy. Contemporary data suggest that moderate surgical delay for localized RCC does not compromise oncologic outcomes.3 As limited surgical delay does not worsen outcomes, and high-volume centers provide more guideline-concordant care, facilitating patient referrals to high-volume centers may represent a partial solution. Patients currently deliberating between immediate surgery at a low-volume community center vs a several month delay for evaluation and treatment at an academic center with robotic capabilities and nephron-sparing expertise may be better served by the latter approach.