Survival of End Stage Renal Failure Patients with Cancer Angela Webster Centre for Kidney Research, The Children’s Hospital at Westmead Department of Renal Medicine, Westmead Hospital, NSW School of Public Health, University of Sydney

Cumulative risk of diagnosis of cancer after start of dialysis Patients at Risk (30,892) Orientate you to this graph We can see that for a patient surving 5 years on dialysis just under 10% will be diagnosed with a non skin cancer (green) this risk rises steadily with time

Cumulative risk of diagnosis of cancer post transplantation Patients at Risk (8,881) For transplant recipients ( cadaveric donor) risk is somewhat higher, with

Australia 2002 6812 people on dialysis 1079 dialysis deaths 63 (5.8%) deaths attributed to cancer Greater number, but smaller proportion of patients on dialysis died of their cancer smaller number, but greater proportion of patients with transplant diesd of their cancer.

Australia 2002 6812 people on dialysis 1079 dialysis deaths 63 (5.8%) deaths attributed to cancer 922 (13.5%) alive with a diagnosis of cancer Greater number, but smaller proportion of patients on dialysis died of their cancer smaller number, but greater proportion of patients with transplant diesd of their cancer.

Australia 2002 6812 people on dialysis 1079 dialysis deaths 63 (5.8%) deaths attributed to cancer 922 (13.5%) alive with a diagnosis of cancer 5466 people with a functioning transplant 149 deaths 37 (25%) deaths attributed to cancer Greater number, but smaller proportion of patients on dialysis died of their cancer smaller number, but greater proportion of patients with transplant diesd of their cancer.

Australia 2002 6812 people on dialysis 1079 dialysis deaths 63 (5.8%) deaths attributed to cancer 922 (13.5%) alive with a diagnosis of cancer 5466 people with a functioning transplant 149 deaths 37 (25%) deaths attributed to cancer 735 (13.4%) alive with a diagnosis of cancer Greater number, but smaller proportion of patients on dialysis died of their cancer smaller number, but greater proportion of patients with transplant diesd of their cancer.

Common cancers 1963-2002

Common cancers 1963-2002

Common cancers 1963-2002

Common cancers 1963-2002

Common non-skin cancers Relative and absolute risks Analysis of survival Attributed cause of death

All non - skin cancers  age matched SA population  per 1000

Survival: all cancers Pre-ESRF Post transplant Dialysis ORIENTATE mean age RR Survival For all cancer types survival is worse for patients on dialysis compared to those transplanted Pts diagnosed pre ESRF are a highly selected population. As you would expect of long term survivors, their death rate is constant with time , total N 1549 mortality steady at 4% per annum For both dialysis and pos trnasplant populations the grwtrest attrition rates are in the first 2 years The overall relative risk of a cancer in dialysis population compared to a normal age matched south australian population is 1.4. median mortalityfor the dialysis population is 0.86/year +just over 10 months The overall relative risk of a cancer in dialysis population compared to a normal age matched south australian population is 3.1 post trnasplant population = 2.23 yrs, 2 years 3 months

Cause of death of cancer patients Cause of death of patients with a cancer diagnosis listed for only 70% patients…… currently exploring the reasons…….. Greater proportion of dialysis patients have missing causes of death. More likely to be listed as causing death for tx pts. Cardiac +social less likely vascular and other relatively steady

Colon cancer  age matched SA population  per 1000

Survival: colon cancer Pre-ESRF Post transplant Dialysis Some cancers seem to have uniformly poor survival numbers pre esrf 150 on dialysis 72 post Tx 93

Attributed cause of death

Attributed cause of death

Lung cancer  age matched SA population  per 1000

Survival: lung cancer Pre-ESRF Dialysis Post transplant Pre esrf 23 on dialysis 155 post tx 103 Post transplant

Attributed cause of death

Attributed cause of death

Melanoma  age matched SA population  per 1000

Survival: melanoma Pre-ESRF Post transplant Dialysis Pre esrf 99 on dialysis 64 post tx 175 mortality in the first year equal, and then we see separation

Attributed cause of death

Attributed cause of death

Conclusions Common cancers in the general population are more common in the ESRF population For any cancer type, survival is worse for patients diagnosed whilst on dialysis than post transplantation Deaths from cancer are proportionally far greater post transplantation

Future directions Re-analysis of survival adjusting for confounders age duration of ESRF Comparison with general population Linkage of databases