Original Investigation
Dialysis
Cancer Incidence Among US Medicare ESRD Patients Receiving Hemodialysis, 1996-2009

https://doi.org/10.1053/j.ajkd.2014.12.013Get rights and content

Background

Patients with end-stage renal disease (ESRD) receiving dialysis have been reported to have increased risk of cancer. However, contemporary cancer burden estimates in this population are sparse and do not account for the high competing risk of death characteristic of dialysis patients.

Setting & Participants

US adult patients enrolled in Medicare’s ESRD program who received in-center hemodialysis.

Factors

Demographic/clinical characteristics.

Outcomes

For overall and site-specific cancers identified using claims-based definitions, we calculated annual incidence rates (1996-2009). We estimated 5-year cumulative incidence since dialysis therapy initiation using competing-risk methods.

Results

We observed a constant rate of incident cancers for all sites combined, from 3,923 to 3,860 cases per 100,000 person-years (annual percentage change, 0.1; 95% CI, −0.4 to 0.6). Rates for some common site-specific cancers increased (ie, kidney/renal pelvis) and decreased (ie, colon/rectum, lung/bronchus, pancreas, and other sites). Of 482,510 incident hemodialysis patients, cancer was diagnosed in 37,128 within 5 years after dialysis therapy initiation. The 5-year cumulative incidence of any cancer was 9.48% (95% CI, 9.39%-9.57%) and was higher for certain subgroups: older age, males, nonwhites, non-Hispanics, nondiabetes primary ESRD cause, recent dialysis therapy initiation, and history of transplantation evaluation. Among blacks and whites, we observed 35,767 cases compared with 25,194 expected cases if the study population had experienced rates observed in the US general population (standardized incidence ratio [SIR], 1.42; 95% CI, 1.41-1.43). Risk was most elevated for cancers of the kidney/renal pelvis (SIR, 4.03; 95% CI, 3.88-4.19) and bladder (SIR, 1.57; 95% CI, 1.51-1.64).

Limitations

Claims-based cancer definitions have not been validated in the ESRD population. Information for cancer risk factors was not available in our data source.

Conclusions

These results suggest a high burden of cancer in the dialysis population compared to the US general population, with varying patterns of cancer incidence in subgroups.

Section snippets

Data and Population

We used data from the USRDS, a national registry that includes all patients in Medicare’s ESRD program. The study population included patients with ESRD 18 years or older who received in-center hemodialysis within the period from April 1, 1995, through December 31, 2010. The study population was restricted to individuals with Medicare as their primary payer and both Parts A and B coverage in order to ensure collection of complete claims data for patients. Patients were excluded for a history of

Annual Incidence Rates of Cancer

Table 1 lists characteristics of the study population of prevalent dialysis patients for selected years of the study period. The number of patients per annual cohort increased each year, from 88,676 in 1996 to 164,214 in 2009. Patients were more likely to be male, be white, or have diabetes as the primary cause of ESRD in recent cohorts. Mean age and mean dialysis vintage increased during the study period.

Adjusted annual incidence rates of cancer are presented in Fig 1. We observed a constant

Discussion

We conducted a large national study of patients with ESRD undergoing hemodialysis to describe the incidence of cancer in this population. After accounting for the substantial competing risk of death in the ESRD population undergoing dialysis, we observed a high cumulative incidence of cancer, with >9% of the ESRD population being diagnosed with cancer during a 5-year period after initiating dialysis therapy. From 1996 through 2009, we observed constant rates of incident cancer diagnoses for all

Acknowledgements

Some of the data reported in this study have been supplied by the USRDS. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the US government.

Support: This research was supported by the National Institutes of Health through contracts from the National Institute of Diabetes and Digestive and Kidney Diseases (2 T32 DK007750-15), the National Cancer Institute (5 T32 CA009330-30), the National

References (47)

  • J.C. Hwang et al.

    High incidence of hepatocellular carcinoma in ESRD patients: caused by high hepatitis rate or 'uremia'? A population-based study

    Jpn J Clin Oncol

    (2012)
  • F.M. Shebl et al.

    Cancer risk among elderly persons with end-stage renal disease: a population-based case-control study

    BMC Nephrol

    (2012)
  • J.H. Stewart et al.

    The pattern of excess cancer in dialysis and transplantation

    Nephrol Dial Transplant

    (2009)
  • J.H. Stewart 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)
  • C.K. Fairley et al.

    The risk of ano-genital malignancies in dialysis and transplant patients

    Clin Nephrol

    (1994)
  • A.F. Kantor et al.

    Cancer in patients receiving long-term dialysis treatment

    Am J Epidemiol

    (1987)
  • J.J. Gaynor et al.

    On the use of cause-specific failure and conditional failure probabilities: examples from clinical oncology data

    J Am Stat Assoc

    (1993)
  • E.L. Korn et al.

    Applications of crude incidence curves

    Stat Med

    (1992)
  • D.Y. Lin

    Non-parametric inference for cumulative incidence functions in competing risks studies

    Stat Med

    (1997)
  • M.S. Pepe et al.

    Kaplan-Meier, marginal or conditional probability curves in summarizing competing risks failure time data?

    Stat Med

    (1993)
  • Researcher's Guide to the USRDS Database: 2013 ADR Edition

    (2013)
  • M.A. Brookhart et al.

    Infection risk with bolus versus maintenance iron supplementation in hemodialysis patients

    J Am Soc Nephrol

    (2013)
  • A.C. Beaubrun et al.

    Temporal trends in fracture rates and postdischarge outcomes among hemodialysis patients

    J Am Soc Nephrol

    (2013)
  • Cited by (0)

    View full text