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Dr. Weal Habhab,MD,FRCPC
Nephrology Consultant
Nephrology Section Head
King Faisal Specialist Hospital -Jeddah
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Controversial, but it is reported to be higher in ESRD
compare to general population
Lancet,1999: international study indicated the standardized
incidence ratio(SIR) of cancer to be 1.18 higher in ESRD
patients.
NDT,2011: study from Taiwan showed the SIR to be 1.4 in
4328 patients in 4.4 years follow up study.
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The risk was higher in
o Younger patients <35
o Female patients
o In the first year of dialysis
Number of new cancer
cases
SIR
95% CI
4328
1.4
1.3–1.4
Male
2069
1.2
1.1–1.3
Female
2259
1.6
1.5–1.7
0–34 years
129
9.2
5.3–16.0
35–54 years
1433
3.5
3.1–3.9
55–65 years
1180
1.7
1.6–1.9
≥65 years
1586
0.8
0.7–0.8
Year 1
723
8.3
7.6–9.0
Year 2
735
3.9
3.6–4.2
Year 3
672
2.9
2.7–3.1
Year 4
581
2.0
1.9–2.2
Year 5
467
1.6
1.5–1.8
Years 6–8
822
1.0
0.9–1.1
>Year 8
328
0.3
0.2–0.3
All patients
Age at first dialysis
Time after first dialysis
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Acquired renal cystic disease
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Medication , CYP
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Infections, HBV and HCV
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Human papilloma virus
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Controversial :
o Infections
o Prolonged chronic uremia impair T-cells and APC functions
o Nutritional abnormality like Vit D deficiency and selenium deficiency
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Bladder
Kidney
Liver
Cervix
Tounge
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USRDS 2007, showed the risk of death from cancer among
ESRD to be 7 deaths per 1000 patients.
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While cardiac arrest resulted in 38 deaths per 1000
patients at the same period.
Benefits
High
mortality
from nonmalignant
causes
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One study examined the benefits of mammography, PSA,
sigmodiscopy and pap smear as screening tools among
ESRD and showed ,
o The costs per unit of survival benefit conferred by cancer screening
were 1.6 to 19.3 times greater among patients with ESRD
compared with the general population
o The net gain of life expectancy in patients with ESRD via these
screening programs was calculated to be five days or less. Similar
survival gains could be obtained by reducing the baseline ESRD
mortality rate by 0.02 percent.
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routine cancer screening in the ESRD population did not
represent an efficient allocation of financial resources
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Similar findings were reported in a study evaluating the
efficacy of breast and cervical cancer screening of
Canadian women undergoing maintenance dialysis.
Colorectal cancer:
In one series, the incidence of guaiac positive stools was three
times higher in asymptomatic dialysis patients compared with
non-ESRD controls .
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Nevertheless, the presence of a positive stool guaiac test in an
asymptomatic individual with ESRD may permit the early
discovery of a colorectal malignancy .
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Prostate cancer
o Screening with PSA still controversial in general population.
o A higher incidence of prostate cancer among patients with ESRD
has been reported .
o Serum PSA levels do not appear to be affected by renal failure
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o But it is not cost effective except in pretransplant evaluation
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Cervical cancer
o The standardized incidence ratio of cervical cancer among
ESRD patients is approximately 2.5 to 4 times that in the normal
population
o This higher risk is due primarily to the increased presence of the
human papilloma virus (HPV) in this patient population.
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Cervical cancer
o Pap smear screening beginning at age 21 years of age
o HPV DNA testing and HPV vaccine, especially in transplant
candidates
o Yearly Pap test in those on transplant waiting lists and in patients
with risk factors and long expected survival based on demographic
factors and comorbid conditions affecting survival in ESRD.
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Breast cancer
o Yearly mammograms and breast examinations for women >40 years
of age and on transplant waiting lists would be reasonable.
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Renal cell carcinoma
Acquired cystic disease is premalignant condition
The incidence is 22% in patient on maintenance dialysis
The incidence of RCC as complication of acquired cystic
disease varies between 2-4%
yearly screening for acquired cystic disease with US to be
performed in patients who have been on dialysis for three
to five years
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Tumor markers:
o The accuracy of other tumor markers in ESRD patients is unknown.
o They are of high molecular weight and ineffectively removed by
dialysis, giving highly false positive rate.
o Still alpha- fetoprotein ,PSA of high value
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Practice guidelines and/or standards for cancer screening
that have been developed in the general population are not
necessarily applicable to patients with end-stage renal
disease (ESRD).
Cancer screening protocols are best implemented on an
individual patient basis.
Special consideration should be given to patients on
transplant list
Routine cancer screening is perhaps most inappropriate in
patients with ESRD who are diabetic, white, or ≥65 years of
age.