Pentafecta for Radical Nephroureterectomy in Patients with High-Risk Upper Tract Urothelial Carcinoma: A Proposal for Standardization of Quality Care Metrics

SIMPLE SUMMARY: Measuring the quality of care is important in health care to improve the treatment of patients. In this investigation, we sought to identify five indicators (“pentafecta”) that reflect the quality of care of patients who have cancer of the upper urinary tract (kidney and/or ureter) and are treated with surgical removal of the affected kidney and ureter. Furthermore, we searched for conditions that can predict a failure to achieve these criteria during treatment. The five indicators that define the pentafecta are the complete removal of the tumor without residuals, the complete removal of the ureter and its bladder part, the absence of complications related to the blood, the absence of severe complications related to the surgery, and the absence of tumor recurrence 12 months after the surgery. Of the 1718 patients included, 844 (49%) achieved all pentafecta criteria. These patients had higher chances at 5 years after the surgery to be alive and not to die from any cause (A) or from cancer (B) compared to those who did not achieve the pentafecta criteria (A: 68.7 vs. 50.1% and B: 79.8 vs. 62.7%, respectively). There were no conditions related to the patient that were found to predict a failure to achieve the pentafecta. Using quality indicators such as the proposed pentafecta for the assessment of the treatment of cancer patients may help define prognosis and improve patient care. ABSTRACT: Background: Measuring quality of care indicators is important for clinicians and decision making in health care to improve patient outcomes. Objective: The primary objective was to identify quality of care indicators for patients with upper tract urothelial carcinoma (UTUC) and to validate these in an international cohort treated with radical nephroureterectomy (RNU). The secondary objective was to assess the factors associated with failure to validate the pentafecta. Design: We performed a retrospective multicenter study of patients treated with RNU for EAU high-risk (HR) UTUC. Outcome measurements and statistical analysis: Five quality indicators were consensually approved, including a negative surgical margin, a complete bladder-cuff resection, the absence of hematological complications, the absence of major complications, and the absence of a 12-month postoperative recurrence. After multiple imputations and propensity-score matching, log-rank tests and a Cox regression were used to assess the survival outcomes. Logistic regression analyses assessed predictors for pentafecta failure. Results: Among the 1718 included patients, 844 (49%) achieved the pentafecta. The median follow-up was 31 months. Patients who achieved the pentafecta had superior 5-year overall- (OS) and cancer-specific survival (CSS) compared to those who did not (68.7 vs. 50.1% and 79.8 vs. 62.7%, respectively, all p < 0.001). On multivariable analyses, achieving the pentafecta was associated with improved recurrence-free survival (RFS), CSS, and OS. No preoperative clinical factors predicted a failure to validate the pentafecta. Conclusions: Establishing quality indicators for UTUC may help define prognosis and improve patient care. We propose a pentafecta quality criteria in RNU patients. Approximately half of the patients evaluated herein reached this endpoint, which in turn was independently associated with survival outcomes. Extended validation is needed.