Mendhiratta N, Sharma V, Wu J et al: Decisional regret and financial toxicity among patients with benign renal masses. Urol Pract 2021; 9: 32.

Over the last few decades, the rising incidence of kidney cancer has been largely driven by the increased detection of small localized renal masses.^1,2 This downward stage migration has led to the detection of more benign disease and indolent tumors, both more prevalent among smaller masses.^3,4 Although most small, benign renal neoplasms pose little risk to the patient, these tumors are often treated because of the inability to reliably differentiate them radiographically from malignant entities. As a result, anywhere from 10%–30% of treated renal tumors may be benign, most commonly renal oncocytoma or fat-poor angiomyolipoma. Estimates of the ensuing treatment-related morbidity, mortality (1 in 500) and cost (over $140 million annually) have been well documented and may largely be considered unnecessary.⁵

Preoperative discrimination of benign masses such as renal oncocytoma is challenging due to the limitations of cross-sectional imaging as well as a low frequency of renal mass biopsy utilization, often driven by concerns that the results will not impact clinical decision making.⁶ While active surveillance has been suggested to have equivalent cancer-specific survival outcomes to primary intervention for small renal masses in well-selected populations, this treatment option is largely underutilized.⁷ Indeed, prior investigations have suggested that interventions offered for kidney cancer are more dependent on provider practice patterns than patient or tumor-related factors.⁸

Understanding the patient experience with treatment of benign renal tumors is important. Anecdotally, some patients may express relief with the discovery that their treated renal mass was benign, while others experience disappointment and frustration with their management and outcome. Significant decisional regret and financial toxicity may burden these patients after treatment and should be recognized and discussed during urological consultation, yet there is a paucity of literature to document this aspect of care. In surveying a cohort of patients with benign renal tumors, we found that nearly 50% of patients expressed significant decisional regret associated with their treatment. Only 42% of patients agreed that their management decision was wise and 39% strongly agreed that they would make the same choice again.⁹ These high levels of decisional regret exceeded those reported from prostate cancer patient cohorts undergoing radical prostatectomy, a treatment with measurable quality of life impairments such as impotence and incontinence.¹⁰ Though qualitative analysis of reported patient experiences identified themes including a lack of discussion that the tumor could be benign as well as distress over postoperative complications, determinants of decisional regret may be complex and worthy of further study as our primary outcome was independent of the treatment chosen, knowledge of the potential for benign disease and presence of treatment-associated complications in multivariate analysis.

Financial toxicity was also notable among respondents, with median comprehensive score for financial toxicity similar to that of a historical validation cohort of patients with stage IV solid organ cancers undergoing chemotherapy. Comprehensive score for financial toxicity was independent of treatment option and estimated household income, and was determined not just by out-of-pocket costs, but also by high toxicity in other domains including financial distress. These data provide novel insights into patient experience with management of small renal tumors, laying the groundwork for further prospective investigation and potential intervention for patients considering treatment for small renal masses.

As urologists, it is imperative to provide as much information as necessary to our patients and further risk stratify tumors before embarking on a treatment course. However, as we continue to refine our methods for pre-treatment disease characterization and counseling, it behooves us to acknowledge the potential for decisional regret and financial toxicity among patients diagnosed with benign renal masses. In doing so, we may better set expectations for patients and potentially improve satisfaction with treatment. Determinants of success for these patients not only should include surgical parameters such as ischemia time and estimated blood loss, but should incorporate the patient experience as well.