Year : 2009 | Volume
: 20 | Issue : 5 | Page : 737--740
Cancer screening in end-stage renal disease
Shobhana Nayak Rao
Bahrain Specialist Hospital, Manama, Bahrain
Shobhana Nayak Rao
Bahrain Specialist Hospital, P.O. Box 10588, Manama
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;20:737-740
|How to cite this URL:|
Rao SN. Cancer screening in end-stage renal disease. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Dec 1 ];20:737-740
Available from: https://www.sjkdt.org/text.asp?2009/20/5/737/55355
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.  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,  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
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. , Acquired renal cysts can be associated with a 1.67% incidence of renal cell carcinoma. Additionally, patients with Balkan nephropathy and analgesic nephropathy have a high risk of tumors of the renal pelvis and ureters.  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  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.  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.  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:
Defects in immunological functions secondary to uremic state.Carcinogenic uremic toxins (nitrosodimethylamine)Impaired anti-oxidant defenses.Vitamin D deficiency.Use of Erythropoeisis stimulating agents.Cumulative immunosuppression.Risk of acquired cystic kidney disease.
Diagnosis of Cancer in dialysis patients
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. , Levels of CA-125 are also altered in patients on CAPD , 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.
Vascular calcification can occur in ESRD and may interfere with the interpretation of mammograms. , 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. ,
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. 
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. , 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.
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