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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 737-740
Cancer screening in end-stage renal disease


Bahrain Specialist Hospital, Manama, Bahrain

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Date of Web Publication2-Sep-2009
 

   Abstract 

The increased risk of cancer after renal transplantation is well documented; however there is less agreement about the prevalence and risk of cancer in patients on dialysis. Although, certain cancers such as those of the kidney and urinary tract are more common among dialysis patients, the extremely high mortality rate of dialysis patients when compared to the normal popu­lation makes cancer screening ineffective both from the cost perspective as well as the survival benefit that is conferred by pre-emptive screening However, with newer improvements in dialysis techniques and better survival of the dialysis population, this issue needs to be addressed.

How to cite this article:
Rao SN. Cancer screening in end-stage renal disease. Saudi J Kidney Dis Transpl 2009;20:737-40

How to cite this URL:
Rao SN. Cancer screening in end-stage renal disease. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Nov 30];20:737-40. Available from: https://www.sjkdt.org/text.asp?2009/20/5/737/55355

   Introduction Top


Cancer screening in the general population serves to detect cancers in the early stages with an aim of curative therapy, especially in pa­tients at risk. Cancer related examination is part of periodic adult health check ups. The Ame­rican Cancer Society recommends screening for breast, colon, cervical, and prostate cancer with specific age and risk related tests. [1] These have been also adopted by the Indian Cancer Society with the additional screening for oral cancer.

The increased risk of cancer after renal trans­plantation is well documented; however there is less agreement about the prevalence and risk of cancer in patients on dialysis. Although, certain cancers are more common among dialysis pa­tients, [2] the extremely high mortality rate of dia­lysis patients when compared to the normal population makes cancer screening ineffective both from the cost perspective as well as the survival benefit that is conferred by pre emptive screening. Routine cancer screening in chronic kidney disease (CKD) has therefore been cri­ticized.

However with newer improvements in dialysis techniques, and better survival of the dialysis population, this issue needs to be addressed. Nephrologists need to be aware of the risks of cancer in dialysis patients and the approach to these patients should be a curative one rather than a palliative one. This article reviews the occurrence and screening of cancer in dialysis patients.


   Evidence for Advocating Screening Top


Cancer and its treatment in subjects with CKD have largely been unstudied. Most cancer drug trials exclude patients with CKD. The frequency of certain cancers is increased in the dialysis population. Patients on maintenance dialysis have increased risk of cancer, especially of the kid­ney and urinary tract. The risk of parenchymal cancer is known to be increased with acquired and inherited cystic disease of the kidney. The risk of acquired renal cysts increases with longer duration on dialysis, and about 50-80% of patients are affected after 10 years. [4],[5] Ac­quired renal cysts can be associated with a 1.6­7% incidence of renal cell carcinoma. Additio­nally, patients with  Balkan nephropathy More Details and analgesic nephropathy have a high risk of tu­mors of the renal pelvis and ureters. [6] Age spe­cific incidence of cancer per 100,000 popula­tion show a 10- fold increase in kidney cancer and a 100 fold increase in bladder cancer [7] in dia­lysis patients. These organs may be susceptible to systemic carcinogenic agents, renal failure related immunological changes, and cytotoxic treatment received for primary renal disease.

Early studies addressing the issue of cancer in dialysis patients showed increased incidence of cancer in end-stage renal disease (ESRD), espe­cially in the first year after initiation of dialysis. The US Renal Data System in 2002 reported a 31% prevalence of cancer in dialysis population. [3] The increased risk of cancer in a larger cohort of dialysis patients was studied by pooled data from the USRDS, EDTA, ANZDTR, which in­cluded 831,804 patients followed up for a mean period of 2.5 years. [2] This data reported a con­sistent increase in the risk of cervical, bladder, thyroid, and renal cell carcinoma (summarized in [Table 1]). There was no significant increase, however, in the risk of breast, colorectal, and prostate cancers when compared to the non­ CKD population. Importantly this study showed a higher risk in patients younger than 35 years. The factors that may account for increased can­cer risk in CKD include:

  1. Defects in immunological functions secon­dary to uremic state.
  2. Carcinogenic uremic toxins (nitrosodimethylamine)
  3. Impaired anti-oxidant defenses.
  4. Vitamin D deficiency.
  5. Use of Erythropoeisis stimulating agents.
  6. Cumulative immunosuppression.
  7. Risk of acquired cystic kidney disease.



   Diagnosis of Cancer in dialysis patients Top


Tumor Markers

Screening tests in dialysis patients can be con­founded by the high incidence of false positive tumor markers in chronic renal failure. Tumor markers are glycoproteins with a relatively high MW (5000-180,000 kd) and not easily removed even by high flux dialysis. However, false posi­tive results are often observed in dialysis pa­tients, thereby, limiting their specificity and use fulness in these patients. Levels of CA-125, Carcino-embryonic antigen (CEA), squamous cell carcinoma antigen (SCC), Neuron specific eno­lase (NSE) can be falsely elevated and have to be interpreted with caution. [8],[9] Levels of CA-125 are also altered in patients on CAPD [10],[11] and have been noted to rise in peritonitis and imme­diately after implantation of the catheter. α-feto protein, α - human chorionic gonadotropin (HC-G) and prostate specific antigen (PSA) are reliable and the most useful tumor markers in ESRD.

Imaging studies

Vascular calcification can occur in ESRD and may interfere with the interpretation of ma­mmograms. [12],[13] The risk of contrast induced acute renal failure or worsening of residual renal function with computerized tomography (CT) as well as the risk of nephrogenic syste­mic fibrosis (NSF) with contrast magnetic re­sonance imaging (MRI) also needs to be addressed in this population. [14],[15]

Stool occult blood testing is also altered by the high incidence of mucosal bleed and gastric and colonic angiodysplasia in patients on dialysis, and it reveals high false positive results. [16]

Therefore, an individualized approach to pa­tients is necessary. The ineffectiveness of the routine cancer screening using mammography, Papanicolaou smears, stool hemooccult testing has been demonstrated in various studies. [17],[18] The life expectancy gained by screening is limited and the cost is high among the patients with ESRD. Screening is advised in patients at risk and periodically in those on the waiting list for deceased donor transplantation. A yearly CT/MRI is also recommended in patients who have been on dialysis for more than 3 years to detect any acquired renal cysts. Applying can­cer screening protocols recommended for the general population to the dialysis patients may not be practical with the short expected life­time on dialysis. As the dialysis population ages, however, the rates of cancer will be higher and nephrologists need to be more pro-active in their approach.

 
   References Top

1.Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer. CA Cancer Clin J 2006; 56:11-25.  Back to cited text no. 1    
2.Maissonoeuve P, Agodoa L, Gellert R, et al. Cancer in patients on dialysis for end stage renal disease: an International Collaborative Study. Lancet 1999;354:93-9.  Back to cited text no. 2    
3.US Renal Data System: USRDS 2002 Annual Data Report: Atlas of End Stage Renal Disease in the United States, Bethesda, National Institute of Health, Diabetes and Digestive and Kidney diseases, 2002.  Back to cited text no. 3    
4.Grantham JJ. Acquired cystic kidney disease. Kidney Int 1991;40:143-52.  Back to cited text no. 4    
5.Ishikawa I, Saito Y, Shikura N, Kitada H, Shinoda A, Suzuki S. Ten year prospective study on the development of renal cell carci­noma in dialysis patients. Am J Kidney Dis 1990;16:452-8.  Back to cited text no. 5    
6.Lornoy W, Becaus S, de Vleeschouwer M, et al. Renal cell carcinoma: A new complication of analgesic nephropathy. Lancet 1986;1:1271-72.  Back to cited text no. 6    
7.Stewart JH, Buccianti G, Agodoa L, et al. Cancers of the Kidney and Urinary Tract in patients on dialysis for End Stage Renal Disease: Analysis of data from the United States, Europe, and Australia and New Zealand. J Am Soc Nephrol 2003;14:197-207.  Back to cited text no. 7    
8.Cases A, Fiella X, Molina R, Ballesta AM, Lopez Pedret J, Revert L. Tumor markers in chronic renal failure and hemodialysis patients. Nephron 1991; 57(2):183-6.  Back to cited text no. 8    
9.Bertolini L, Meschi M, Detremis S, Maggiore U, Savazzi G. Serum concentration of some tumor markers in renal failure. Recenti Prog Med 2005; 96(5):221-5.  Back to cited text no. 9    
10.Krediet RL. Dialysate cancer antigen 125 concentration as marker of peritoneal membrane status in patients treated with chronic peritoneal dialysis. Perit Dial Int 2001;21(6):560-7.  Back to cited text no. 10    
11.Bastani B, Chu N. Serum CA-125 level in end­stage renal disease patients maintained on chronic peritoneal dialysis or hemodialysis: the effect of continuous presence of peritoneal fluid, perito­nitis and peritoneal catheter implantation. Am J Nephrol 1995;15:468-72.  Back to cited text no. 11    
12.Evans AJ, Cohen EJ, Cohen GF. Patterns of breast calcification in patients on renal dialysis. Clin Radiol 1992;45:343-4.  Back to cited text no. 12    
13.Castellanos MR, Paramanathan K, El-Sayegh S, Buchbinder S, Kleina M. Breast cancer screening in women with chronic kidney disease: the unrecognized effects of metastatic soft tissue calcification. Nat Clin Pract Nephrol 2008; 4: 337-41.  Back to cited text no. 13    
14.Marckmann P, Skov L, Rossen K, et al. Nephro­genic systemic fibrosis: Suspected causative role of gadodiamide used for contrast enhanced magnetic resonance imaging. J Am Soc Nephrol 2006;17:2359-62.  Back to cited text no. 14    
15.Townsend RR, Cohen DL, Katholi R, et al. Safety of gadolinium (GO -BOPTA) infusion in patients with renal insufficiency. Am J Kidney Dis 2000;36:1207-12.  Back to cited text no. 15    
16.Rockey DC, Koch J, Cello JP, Sanders LL, Mc Quaid K. Relative frequency of upper gastro­intestinal and colonic lesions in patients with positive fecal occult blood tests. N Engl J Med 1998;339:153-9.  Back to cited text no. 16    
17.Kajbaf S, Nichol G, Zimmerman D. Cancer screening and life expectancy of Canadian patients with kidney failure. Nephrol Dial Transplant 2002;17:1786-9.  Back to cited text no. 17    
18.Chertow GM, Paltiel AD, Owen WF, Lazarus JM. Cost effectiveness of cancer screening in end stage renal disease. Arch Intern Med 1996; 156:1345-5.  Back to cited text no. 18    

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Correspondence Address:
Shobhana Nayak Rao
Bahrain Specialist Hospital, P.O. Box 10588, Manama
Bahrain
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PMID: 19736467

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    Tables

  [Table 1]

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