NKCA SotN 2024 Report
Source: data.gov.uk (2024-09-19)

National Kidney Cancer Audit State of the Nation Report 2024. The National Kidney Cancer Audit (NKCA) aims to evaluate the patterns of care and outcomes for people with kidney cancer in England and Wales, using routinely collected data and to support services to improve their care quality.

This State of the Nation report aims to help NHS organisations to benchmark their kidney cancer care against measurable standards, to identify unwarranted variation in measures of processes and outcomes, and to describe national levels and patterns of these measures in England and Wales.

The performance indicators include people diagnosed with kidney cancer between January 2017 to December 2021 in England using the National Cancer Registration Dataset (NCRD), and January 2022 to December 2022 in Wales. It reports on eight performance indicators for England and four for Wales outlined in the NKCA Quality Improvement Plan 2024. The report also describes the national picture and variation between NHS trusts in England/Health Boards in Wales. 

For the national picture sections, we use the most recently available data in England from the Rapid Cancer Registration Dataset (RCRD) reporting on people diagnosed between 1st January 2019 and 30th September 2023, and in Wales between 1st January 2022 and 31st December 2022.

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National Kidney Cancer Audit
State of the Nation Report 2024
An audit of care received by people diagnosed with kidney cancer in England (January 2017-December 2021) 
and Wales (January-December 2022).
National time trends in kidney cancer diagnoses and treatments in England (January 2019-September 2023)
Published September 2024

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Citation for this document: 
National Kidney Cancer Audit (NKCA) State of 
the Nation Report 2024 London: 
National Cancer Audit Collaborating Centre, 
Royal College of Surgeons of England, 2024.
This document was prepared by members of the NKCA project team:
Amit Bahl (BUG) – Clinical Lead Oncology
Grant Stewart (BAUS) – Clinical Lead Surgery
Jan van der Meulen – Senior Methodologist 
Thomas Cowling – Senior Methodologist 
Emily Mayne – Data Scientist 
Cressida Miller – Senior Project Manager
Marina Parry – Senior Project Manager
Raghav Varma – Clinical Fellow
With review and input from: 
NKCA Clinical Reference Group 
NATCAN Executive Team
The Royal College of Surgeons of England (RCS) is an independent professional body committed 
to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient 
care. As part of this it supports audit and the evaluation of clinical effectiveness for surgery. 
Registered Charity no: 212808.
The National Cancer Audit Collaborating Centre (NATCAN) is commissioned by the Healthcare 
Quality Improvement Partnership (HQIP) as part of the National Clinical Audit and Patient Outcomes 
Programme (NCAPOP). NATCAN delivers national cancer audits in non-Hodgkin lymphoma, bowel, 
breast (primary and metastatic), oesophago-gastric, ovarian, kidney, lung, pancreatic and prostate 
cancers. HQIP is led by a consortium of the Academy of Medical Royal Colleges and the Royal 
College of Nursing. Its aim is to promote quality improvement in patient outcomes, and in particular, 
to increase the impact that clinical audit, outcome review programmes and registries have on 
healthcare quality in England and Wales. HQIP holds the contract to commission, manage and 
develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 
40 projects covering care provided to people with a wide range of medical, surgical, and mental 
health conditions. The programme is funded by NHS England, the Welsh Government and, with some 
individual projects, other devolved administrations and crown dependencies.  
https://www.hqip.org.uk/national-programmes
The British Association of Urological Surgeons (BAUS) was founded in 1945 and exists to promote 
the highest standards of practice in urology, for the benefit of patients, by fostering education, 
research and clinical excellence. BAUS is a registered charity and qualified medical practitioners 
practising in the field of urological surgery are eligible to apply for membership. Registered Charity 
no: 1127044
The British Uro-oncology Group (BUG) was formed in 2004 to meet the needs of clinical and 
medical oncologists specialising in the field of urology. As the only dedicated professional 
association for uro-oncologists, its overriding aim is to provide a networking and support forum for 
discussion and exchange of research and policy ideas. Registered Charity no: 1116828
This work uses data that has been provided by patients and collected by the NHS as part of their 
care and support. For patients diagnosed in England, the data is collated, maintained and quality 
assured by the National Disease Registration Service (NDRS), which is part of NHS England. Access 
to the data was facilitated by the NHS England Data Access Request Service.
NHS Wales is implementing a new cancer informatics system. As a result, the quality and 
completeness of data from Wales is likely to have been impacted due to implementation of this new 
system across multiple NHS organisations (Health Boards), which has resulted in data being supplied 
by both old and new systems. Additionally, and reflecting the uncertainty of data quality, the data 
submitted to the audit may not have undergone routine clinical validation prior to submission to the 
Wales Cancer Network (WCN), Public Health Wales.
© 2024 Healthcare Quality Improvement Partnership (HQIP)
Copyright All rights reserved. No part of this publication may be reproduced in any form (including photocopying or storing it in any medium by electronic means and whether 
or not transiently or incidentally to some other use of this publication) without the written permission of the copyright owner. Applications for the copyright owner’s written 
permission to reproduce any part of this publication should be addressed to the publisher.

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Contents
1.	
Introduction	
4
Infographic English results	
6
Infographic Welsh results	
7
2.	
Recommendations	
8
3.	
Results for England	
10
3.1	
Data completeness and patient characteristics	
10
3.2	
Performance indicators	
10
3.3	
National time trends in kidney cancer diagnoses and treatments	
13
4.	
Results for Wales (2022) 	
15
4.1	
Data completeness and patient characteristics	
15
4.2	
Performance indicators	
15
4.3	
National picture of kidney cancer treatment in 2022	
16
5.	
Commentary	
17

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1.	 Introduction
The National Kidney Cancer Audit (NKCA) aims 
to evaluate the patterns of care and outcomes for 
people with kidney cancer in England and Wales, 
using routinely collected data and to support 
services to improve their care quality.
This State of the Nation report aims to help NHS 
organisations to benchmark their kidney cancer 
care against measurable standards, to identify 
unwarranted variation in measures of processes 
and outcomes, and to describe national levels and 
patterns of these measures in England and Wales.
Along with this document and lay summary, further 
resources are available at: https://www.natcan.org.
uk/audits/kidney/. These include individual NHS 
provider results, the appendix, action plan template 
to support local quality improvement projects, a 
detailed description of the audit methodology and 
the NKCA Quality Improvement Plan 2024 which 
sets out the scope, care pathway, and quality 
improvement goals. This report focuses on eight 
indicators of performance of NHS providers to drive 
improvements in kidney cancer care (Table 1).
This State of the Nation report provides a national 
perspective on the patterns of kidney cancer care 
and outcomes across England and Wales. This 
year it includes people diagnosed with kidney 
cancer between January 2017 to December 2021 
in England, and January 2022 to December 2022 
in Wales. It reports on 8 out of the 10 performance 
indicators for England, and 4 out of the 10 
performance indicators for Wales outlined in the 
NKCA Quality Improvement Plan 2024. The report 
describes the national picture and variation between 
NHS trusts in England/ Health Boards in Wales. 
Findings in the report lead to five recommendations 
to drive improvements in the quality of kidney 
cancer care. The State of the Nation report will be 
published annually. In future years the NKCA will 
work to align the reporting periods in England and 
Wales, and to provide more timely reporting. In 
England this will require the use of Rapid Cancer 
Registration Data (RCRD) as well as ‘gold standard’ 
National Cancer Registration Data (NCRD)1, and 
development work is needed to ensure the RCRD is 
of sufficient data quality. Future reports will evaluate 
change in care and outcomes over time, as well as 
variation between organisations.
The NKCA also provides timely quarterly reports 
of data quality to NHS trusts in England. Data 
quality reports provide a local perspective on the 
completeness of data available on people with 
kidney cancer at individual NHS organisations and 
shine a spotlight on areas where improvements to 
data collection are needed. Good quality data is 
essential for the audit to produce reliable and robust 
information. The most recent data quality report was 
on data spanning January 2021 to December 2023, 
and reports are updated every three months.
The NKCA will shortly begin quarterly reporting of 
performance indicators for NHS trusts in England 
(expected October 2024). These will be updated 
every three months and will provide timely 
reporting on the performance indicators outlined 
in the NKCA Quality Improvement Plan 2024. The 
intended audience is NHS trusts; supporting them 
to track progress alongside local quality 
improvement activities. 
A summary of this report for people diagnosed with 
kidney cancer and the public will be made available 
on the NKCA’s webpages. Details of the methods are 
available in the NKCA Methodology Supplement and 
a glossary is provided of terminology in this report.
Further information about the outlier process can be 
found in the FAQs for NATCAN (point 17).
1	
The audits in NATCAN do not ‘collect’ clinical data. The cancer audits utilise the nationally mandated flows of data from hospitals to the National Disease Registration 
Service (NDRS) in NHSE and the Wales Cancer Network in Public Health Wales, thereby minimising the burden of data collection on provider teams. Further information 
about the timeliness of National Cancer Registration Dataset (NCRD) can be found on the NATCAN website https://www.natcan.org.uk/resources/timeliness-of-the-
national-cancer-registration-dataset-ncrd/

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Table 1. Cancer registration dataset and time period that define the population for each performance indicator
Performance indicators 
England
Wales
PI1: Percentage of people with kidney cancer with the data completeness 
measure recorded for MDT meeting
National Cancer 
Registration Dataset 
(NCRD)
People with kidney 
cancer diagnosed 
between
01/xx-xxxx-xxxx
Cancer Network 
Information System 
Cymru (CaNISC)
People with kidney 
cancer diagnosed 
between
01/xx-xxxx-xxxx
PI2: Percentage of people with kidney cancer who are consented for a 
clinical trial (England only)*
PI3: Percentage of people with a small renal mass (≤4cm) who have a 
biopsy (England only)*
PI4: Percentage of people with a T3+ and/or 10cm+ and/or N1 and M0 renal 
cell carcinoma (RCC)** who have a radical nephrectomy within 31 days of 
diagnosis (England only)*
PI5: Percentage of people with T1b-3NxM0 RCC (T2-3NxM0 RCC for 
Wales)** who have surgery 
PI6: Percentage of people with T1aN0M0 RCC** who undergo nephron 
sparing treatment 
PI7: Percentage of people presenting with M1 RCC who have initial SACT 
within 12 months of diagnosis
NCRD
People with kidney 
cancer diagnosed 
between
01/xx-xxxx-xxxx
PI8: Percentage of people with kidney cancer who die within 30 days of 
starting SACT treatment
*Measured in England only due to the availability of relevant data for Wales. MDT: Multi-disciplinary team; SACT: systemic anti-cancer therapy.
Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-2021
T3+ and/or 10cm+ and/or N1 and M0 RCC
Tumour extends into major veins or perinephric tissues or invades beyond Gerota 
fascia and/or tumour more than 10cm in size and/or metastasis in regional lymph 
node(s) with no distant metastasis
T2-3NxM0 RCC
Tumour is more than 7cm in size or tumour extends into major veins or perinephric 
tissues with no distant metastasis
T1b-3NxM0 RCC
Tumour is more than 4cm in size or tumour extends into major veins or perinephric 
tissues with no distant metastasis
T1aN0M0 RCC
Tumour is less than or equal to 4cm in size with no regional lymph node metastasis 
and no distant metastasis
** UICC TNM8 Kidney Cancer
 We report a three-year period for England to 
ensure sufficient patient numbers to be able to 
reliably estimate each provider’s performance. 
Similarly, indicators on SACT are reported for a 
five-year period (2017-2021) for England due to the 
relatively small number of people diagnosed with 
metastatic disease in each provider (see Table 1). 
For Wales, data for only one year were available2. 
Due to the different periods covered, and 
differences in the construction of some indicators, 
results for England and Wales are presented 
separately. We aim to align the data from Wales 
and England in future reports and present the 
combined results. NKCA analyses gold standard 
data for performance indicators but also utilises 
Rapid Cancer Registration Dataset (RCRD) to 
illustrate the change in diagnosis and treatment 
over time.
2	
NHS Wales is part way through a cancer informatics implementation programme which is designed to improve the data capture and reporting capabilities of NHS Wales. 
This ongoing implementation is impacting the data quality within NHS Wales in the short term with multiple systems being used and different implementation dates 
across cancer sites and organisations resulting in a complex data landscape. NHS Wales has committed to continue to submit audit data annually until data submissions 
are sourced exclusively from the new cancer informatics solution. This will be from 2026 onwards that NHS Wales will be able to supply quarterly data using this new 
integrated, and more accessible digital platform.

Infographic English results
of people had metastases
Diagnosis & staging
28,229
people were 
diagnosed wit kidney 
cancer in  - 
age at diagnosis 
(median)
Interquartile range 
59 - 77 years
of people with kidney cancer 
were diagnosed at stage T1 
and any N/M category
of people were male
of people with kidney 
cancer had a multi-
disciplinary team meetin 
recorded*
Treatment Allocation
Surgery
Systemic Anti-Cancer Terapy SACT
of people with a small renal 
mass had a biopsy
of people with a T3 or 10c+ or N1 and 
M0 Renal Cell Carcinoa RCC had 
radical nephrectomy within  days of 
decision to treat.  
of people with T1b-3NxM0 RCC 
underwent surgery
of people with T1aN0M0 underwent 
nephron sparing treatment
of people with metastatic RCC received initial 
SACT within 1 months of diagnosis 
of people with kidney cancer 
died within  days of SACT 
treatment
of people with kidney 
cancer had consented for a 
clinical trial 
T3 and/or 10cm+ and/or N1 and M0 RCC 
- 
Tumour 
extends 
into 
major 
veins 
or 
perinephric 
tissues 
or 
invades 
beyond 
Gerota 
fascia 
and/or 
tumour 
more 
than 
cm 
in 
size 
and/or
metastasis in regional lymph node(s)
T1b-3NM0 RCC - Tumour is more than cm in size or tumour extends into major veins or perinephric tissues with no distant metastasis
T1aN0M0 RCC - Tumour is less than or eual to cm in size with no regional lymph node metastasis and no distant metastasis
Data completeness measure
England Infographic 209  202
69
years
58%
21%
64%
82%
2%
69%
76%
48%
3%
67%
20%
Infographic for English results

Infographic Welsh results
86
21
people with T23NxM0 RCC
underwent surger y
people with T23NxM0 RCC
did not have surger y
0
50
100
of people with T23NxM0 
Renal Cell Carcinoma RCC 
underwent surgery 
Diagnosis  staging
490
people were 
diagnosed with kidney 
cancer in 
age at diagnosis 
(median)
Interquartile range 
60 - 78 years
of people with kidney cancer 
were diagnosed at stage T1 
and any N/M category
of people were male
of people with kidney 
cancer had a mlti-
discilinary team 
meeting recorded*
Treatment Allocation
Systemic Anti-Cancer Therapy SACT
of people with metastatic RCC 
received initial SACT within  
months of diagnosis 
of people with kidney cancer 
died within  days of SACT 
treatment
Data completeness measure
Wales Infographic 
70
years
46%
21%
65%
99%
57%
Number of people
80%
38
2
people with metastatic
disease received SACT
people with metastatic
disease did not receive SACT
0
25
50
Number of people
2
57
people with kidney cancer
who died within 30 days of 
receiving SACT
people with kidney cancer
who did not die within 30
days of receiving SACT
0
50
100
3%
Number of people
T3 and/or 10cm+ and/or N1 and M0 RCC  Tumour extends into major veins or perinephric tissues or invades beyond Gerota fascia and/or tumour more than 
10cm in size and/or metastasis in regional lymph node(s)
T23NM0 RCC  Tumour is more than cm in size or tumour extends into major veins or perinephric tissues with no distant metastasis
T1aN0M0 RCC  Tumour is less than or eual to cm in size with no regional lymph node metastasis and no distant metastasis
of people had metastases
Infographic for Welsh results

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2.	 Recommendations
Recommendation
Audience
Audit findings 
Quality Improvement Goal
National guidance/standards/resources
1.	 Increase the number of people 
with a small renal mass who 
receive a renal mass biopsy to 
confirm the histological diagnosis, 
by improving availability of timely 
diagnostics.**
England 
ICBs working with 
trusts
Wales 
Health boards
England: The percentage of people 
with a small renal mass who have a 
renal mass biopsy was 20%, with an 
NHS Trust-level interquartile range 
of 8-28%. 
To increase the use of renal 
tumour biopsy
The Getting It Right First Time (GIRFT) Academy 
developed a guide on the management of kidney 
cancer. They recommend offering renal mass biopsy, 
where technically feasible, if it will impact patient's 
choice or clinician's recommendation on treatment for 
patients with solid small renal masses. 
NKCA standard that 25% of providers perform better 
than* 28% (England).
2.	 Review pathways for higher risk 
renal cell carcinoma (RCC) to 
understand system-level delays 
and ensure providers treat these 
people within 31 days from 
decision to treat in England and 21 
days in Wales.**
England 
Cancer Alliances 
working with trusts
Wales 
Health boards
England: The percentage of people 
with a T3+ and/or 10cm+ and/or N1 
and M0 RCC tumour who have a 
radical nephrectomy within 31 days 
of decision to treat was 69% with an 
NHS Trust-level interquartile range 
of 61-77%. 
To expedite treatment of 
people with potentially high 
risk for recurrence localised 
and locally advanced RCCs 
(i.e. cT3+, 10cm+, cN1 
tumours)
GIRFT recommends fast-tracking the assessment 
of people with higher risk disease (>10cm, cT3+, 
cN1 tumours) and expediting their treatment. The 
benchmark defined for cancer waiting times from 
decision to treat to treatment is 31 days in England and 
21 days in Wales.
NHS England’s standard set at 96%.
NKCA standard that 25% of providers perform better 
than* 77% (England). 
3.	 Identify and address reasons why 
people with kidney cancer, stage 
T1b-3Nx RCC are not considered 
for surgical treatment and increase 
the number of eligible people.
England 
Cancer Alliances 
working with trusts
Wales 
Health boards
England: The percentage of people 
with T1b-3NxM0 RCC who have 
surgery was 76%. This is with an 
NHS Trust-level interquartile range 
of 69-83%. 
Wales: The percentage of people 
with T2-3NxM0 RCC who have 
surgery was 80% with a health board 
interquartile range of 69-85%.
To increase use of surgery, 
if medically appropriate, for 
initially localised RCC at risk 
of progression
Kidney Cancer UK (KCUK) Accord Report 2022 
measured the quality of kidney cancer services in 
England between 2017 to 2018 and emphasised the 
importance of prioritising curative surgery for T1b-
3NxM0 RCC if medically appropriate (QPI2). 
NKCA standard that 25% of providers perform better 
than* 83% (England). 
NKCA standard that 25% of providers perform better 
than* 85% (Wales). 
*Upper quartile of performance indicator values at the NHS trust or Health Board (in Wales) level. These figures were calculated without risk-adjustment and may be revised in future iterations of this report once risk-adjustment has been applied to 
understand appropriate target levels.
**Measured in England only due to the availability of relevant data for Wales.

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Recommendation
Audience
Audit findings 
Quality Improvement Goal
National guidance/standards/resources
4.	 Ensure that people with kidney 
cancer, stage T1aN0M0 RCC 
are discussed in specialist 
multidisciplinary team meetings 
and offered nephron sparing 
treatment.**
England 
Cancer Alliances 
working with trusts
Wales 
Health boards
England: The percentage of people 
with T1aN0M0 RCC who undergo 
nephron sparing treatment was 67% 
with an NHS Trust-level interquartile 
range of 52-78%.
To reduce the use of 
unnecessary extensive 
surgery for low-risk RCC
Better Cancer Ambition and Action (2016) recognised 
the need for national cancer QPIs to support a culture 
of continuous quality improvement. Scottish QPI7 
aims to improve the percentage of people with T1a 
renal cancer receiving nephron sparing treatment 
to preserve renal function and reduce frequency of 
cardiovascular events.
NKCA standard that 25% of providers perform better 
than* 78% (England). 
5.	 Ensure people diagnosed with 
metastatic RCC are evaluated 
by a medical/clinical oncologist 
with expertise in renal cancer 
management and receive systemic 
anti-cancer therapy (SACT).
England 
Cancer Alliances 
working with trusts
Wales 
Health boards
England: The percentage of people 
with metastatic RCC receiving initial 
SACT within 12 months of diagnosis 
was 48%. This is with an NHS Trust-
level interquartile range of 40-57%.
Wales: The percentage of people 
with metastatic RCC receiving initial 
SACT within 12 months of diagnosis 
was 57%. This is with a health board 
interquartile range of 50-78%. 
To increase use of evidence 
based SACT treatment in 
eligible people with kidney 
cancer without severe toxicity
KCUK Accord QPI4 and Scottish QPI9 aim to increase 
the number of people with metastatic RCC receiving 
SACT as clinical trials show it can improve quality of life 
and extend survival.
NKCA standard that 25% of providers perform better 
than* 57% (England). 
NKCA standard that 25% of providers perform better 
than* 78% (Wales). 
*Upper quartile of performance indicator values at the NHS trust or Health Board (in Wales) level. These figures were calculated without risk-adjustment and may be revised in future iterations of this report once risk-adjustment has been applied to 
understand appropriate target levels.
**Measured in England only due to the availability of relevant data for Wales.

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3.	 Results for England
3.1	 Data completeness and patient 
characteristics
We analysed the National Cancer Registration 
Dataset (NCRD) for 28,229 people diagnosed with 
kidney cancer in England from 1st January 2019 to 
31st December 2021 (Table A1) with 24,589 (92%) 
people being from the white ethnic group, of 
those known.
Data were complete for: 79% of T, 72% of N, and 
77% of M category of stage values (Table A1); 
76% of stage grouping (1-4) data were complete. 
Completeness of ethnicity (94%), performance 
status (40%), and tumour size (65%) data items 
could also be improved and have been included in 
our quarterly report of data quality (uses RCRD for a 
more recent cohort of people with kidney cancer).
The median age at diagnosis was 69 years overall 
(IQR 59-77). There were more male (64%) people 
than female (36%) in keeping with kidney cancer 
statistics presented by Cancer Research UK. In 
people with a T, N, or M stage recorded 
respectively, the percentage of people with a T1-2 
stage was 68%; 10% of people had nodal disease 
(N1), and 21% had metastatic disease (M1). 
Table 2. Performance indicators for people with kidney cancer diagnosed and treated in England
National 
percentage 
%
Median %
(IQR %)
[range %; Trust n]
No. of people 
with kidney 
cancer (total)
No. of 
events
Time 
period
PI1: Percentage of people with kidney cancer 
with the data completeness measure recorded 
for MDT meeting
82%
84%
(74-92%)
[20-98%; n=123]
28,229
23,210
2019-21
PI2: Percentage of people with kidney cancer 
consented for a clinical trial*
2%
1%
(0-3%)
[0-15%; n=122]
21,908
352
2019-21
PI3: Percentage of people with a small renal 
mass who have a biopsy*
20%
17%
(8-28%)
[0-75%; n=108]
6,614
1,330
2019-21
PI4: Percentage of people with a T3+ and/
or 10cm+ and/or N1 RCC** who had a radical 
nephrectomy within 31 days of diagnosis*
69%
70%
(61-77%)
[39-94%; n=100]
4,539
3,124
2019-21
PI5: Percentage of people with T1b-3NxM0 
RCC** who have surgery 1 month prior and 12 
months following diagnosis
76%
75%
(69-83%)
[19-98%; n=115]
9,093
6,873
2019-21
PI6: Percentage of people with T1aN0M0 
RCC** who undergo nephron sparing treatment 
1 month prior and 12 months following 
diagnosis
67%
66%
(52-78%)
[7-100%; n=91]
3,804
2,558
2019-21
PI7: Percentage of people with metastatic 
RCC receiving initial SACT within 12 months of 
diagnosis
48%
46%
(40-57%)
[15-81%; n=120]
7,949
3,812
2017-21
PI8: Percentage of people with kidney cancer 
who die within 30 days of SACT treatment
3%
3%
(0-6%)
(0-20%; n=77)
5,228
173
2017-21
IQR: Interquartile range; MDT: multi-disciplinary team; RCC: renal cell carcinoma; SACT: systemic anti-cancer therapy. All numbers in this table are unadjusted. We have 
included median and IQR as these offer a better representation of skewed, non-normal distributions than mean (standard deviation). Trusts with less than 10 patients in 
their denominator were excluded from medians, IQRs, ranges and Trusts in above.
*12 months following diagnosis was measured to capture all people with kidney cancer who underwent treatment. Timeframe to treatment was not assessed in these 
performance indicators. 
Data were impacted by the COVID-19 pandemic and so will be atypical to some degree during 2020-2021
3.2	 Performance indicators
T3+ and/or 10cm+ and/or N1 and 
M0 RCC
Tumour extends into major veins or perinephric tissues or invades beyond Gerota fascia and/
or tumour more than 10cm in size and/or metastasis in regional lymph node(s) with no distant 
metastasis
T2-3NxM0 RCC
Tumour is more than 7cm in size or tumour extends into major veins or perinephric tissues 
with no distant metastasis
T1b-3NxM0 RCC
Tumour is more than 4cm in size or tumour extends into major veins or perinephric tissues 
with no distant metastasis
T1aN0M0 RCC
Tumour is less than or equal to 4cm in size with no regional lymph node metastasis and no 
distant metastasis
** UICC TNM8 Kidney Cancer

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11
Treatment planning
Key messages: 82% of people diagnosed 
with kidney cancer (23,210 patients) between 
1st January 2019 and 31st December 2021 
in England were recorded to have been 
discussed at an MDT meeting, with an NHS 
trust-level interquartile (IQR) of 74-92%. 
During this period, only 2% (352 patients) 
were recorded to have consented to a clinical 
trial with an NHS trust-level IQR of 0 - 3% 
(Table 2). NHS trusts should improve data 
completeness for whether people diagnosed 
with kidney cancer were discussed at MDT 
meetings and increase the number of people 
consenting to participate in clinical trials. 
This aligns with NHS England initiatives on 
promoting research to improve patient care - 
‘Embedding Research in the NHS’.
Kidney cancer MDT guidance, published in 2012 by 
the British Association of Urological Surgeons 
(BAUS) and the British Uro-oncology Group (BUG), 
aims to avoid fragmentation and improve 
collaboration in patient care. The Scottish QPI4 
MDT target is 95%, and it was surpassed in 2020, 
reaching 95.9%. However, poor data completeness 
for this metric at 82% makes it difficult to 
determine performance levels. The reasons for poor 
data completeness are likely to vary across 
organisations and data items – recording of 
information at MDT, data entry/audit resource etc. 
The Audit will further explore data completeness 
and try to build a clearer picture of the issues in 
submission of data for people with kidney cancer, 
to build on this in future publications.
KCUK Accord QPI5 found 500 people with RCCs 
(2.7% of the cohort) between 1st January 2017 and 
31st December 2018 had evidence of clinical trial 
participation. At the Trust level the proportion of 
people with RCC with evidence of clinical trial 
participation ranged from 0.3% to 16.3% which 
aligns with the current range of clinical trial 
participation at NHS trusts, spanning from 0 – 15%, 
as shown above. Viewed at national level, there is a 
very low overall level of access to clinical trials. 
This is of concern as people with kidney cancer are 
not getting access to the newest kidney cancer 
treatments via clinical trials.
Use of renal biopsy
Key messages: In England between 1st 
January 2019 and 31st December 2021, 20% 
of people with kidney cancer (1,330 patients) 
presenting with a less than or equal to 4cm 
renal mass had a biopsy to confirm the 
histological diagnosis, with an NHS trust-level 
IQR of 8 – 28% (Table 2). NHS trusts should 
ensure they have adequate capacity and 
increase the use of timely renal biopsy for 
small renal masses to confirm the histological 
diagnosis, in keeping with the recommendation 
from GIRFT.
GIRFT made this recommendation to assist in 
pre-operative counselling for people with kidney 
cancer, offering clarity for those choosing active 
treatments like surgery or ablation, and reassurance 
for people with non-cancerous masses who may 
prefer to avoid invasive therapies. During this 
timeframe, 80% (6,614 patients) of people with a 
small renal mass did not have a biopsy to help 
guide pre-operative counselling.
Curative treatment for renal cell carcinoma
Key messages: Between 1st January 2019 
and 31st December 2021, 69% of people with 
kidney cancer in England, (3,124 patients) with 
a T3+ and/or 10cm+ and/or N1 and M0 RCC 
had a radical nephrectomy within 31 days of 
decision to treat among those who had surgery, 
with an NHS trust-level IQR of 61 – 77%. The 
benchmark defined for cancer waiting times 
from decision to treat to treatment is 31 days, 
with NHS England’s standard set at 96%. 
For those with T1b-3NxM0 RCC, 76% (6,873 
patients) had surgery within 1 month prior and 
12 months following diagnosis, with an NHS 
trust-level IQR of 69 - 83% (Table 2). These 
two indicators provide information on ensuring 
timely management for people with RCC 
amenable to surgical treatment. NHS trusts 
should ensure timely curative treatment for 
people with RCC.
This relates to the GIRFT recommendation of 
prevention of metastatic disease by earlier 
management of high-risk, localised disease. It was 
found that 31% of people with high-risk, localised 
and locally advanced RCC did not have timely 
access to surgical treatment.

Copyright © 2024 Healthcare Quality Improvement Partnership (HQIP)
12
24% is a high percentage of all T1b-3NxM0 cases 
not to receive curative surgery within 12 months 
of diagnosis. Between 1st January 2017 and 31st 
December 2018, KCUK Accord QPI2 found 72.9% 
T1b-T3 RCC received radial nephrectomy surgery up 
to 1 month prior to 6 months following diagnosis. 
Nephron sparing treatment for T1a renal cell 
carcinoma
Key messages: In people with T1aN0M0 RCC 
who underwent treatment within 1 month prior 
and 12 months following diagnosis between 
1st January 2019 and 31st December 2021 in 
England, 67% (2,558 patients) had nephron 
sparing treatment (partial nephrectomy and 
thermal ablation). This performance indicator 
had an NHS trust-level IQR of 52-78% (Table 
2). Therefore, 33% of people with T1aN0M0 
underwent radical nephrectomy. NHS trusts 
should increase the percentage of people with 
T1a tumours who undergo nephron sparing 
treatment.
The Scottish QPI7 highlights the importance of 
nephron sparing treatment for T1aN0M0 RCC to 
help preserve renal function, reduce frequency of 
cardiovascular events and increase quality of life 
for people. The percentage of nephron-sparing 
treatment in Scotland reached 83.5% in 2020. Our 
results suggest nephron sparing treatment may be 
underutilised in England.
Systemic anticancer therapy for metastatic renal 
cell carcinoma
Key messages: Between 1st January 2017 
and 31st December 2021, 48% of people with 
metastatic RCC (3,812 patients) in England 
received initial SACT within 12 months of 
diagnosis. The IQR across NHS trusts was 40 
– 57%. In addition, 3% of people died within 30 
days of SACT treatment, with an NHS trust IQR 
of 0 – 6% (Table 2). NHS trusts should increase 
timely access to SACT, while reducing severe 
associated toxicity.
The Scottish QPI9 emphasised the use of SACT 
as clinical trials have demonstrated it can improve 
quality of life, extend survival, and improve cancer 
related symptoms for people with metastatic RCC. 
Scotland QPI9 in 2020 found 62.2% of people 
with advanced (T4N0M0) and/or metastatic RCC 
receiving initial SACT in the first year after diagnosis. 
Between 1st January 2017 and 31st December 2018, 
KCUK Accord QPI4 found just under half of M1 RCC 
(47.4%) received SACT up to one month prior and 
one year following diagnosis. 48% may suggest that 
SACT is being underutilised nationally. 
In addition, the Scottish QPI15 monitors the 30-day 
mortality after SACT to ensure care is safe, effective 
and person-centred. They found a 4.5% (25 out 
of 558) 30-day mortality for kidney cancer across 
Scotland in 2022. In England 3% of people died 
within 30 days of SACT treatment, when measured 
from the first cycle.

Copyright © 2024 Healthcare Quality Improvement Partnership (HQIP)
13
3.3	 National time trends in kidney cancer 
diagnoses and treatments
Using the Rapid Cancer Registration Dataset (RCRD), 
we demonstrate the national trends in the diagnosis 
and treatment of kidney cancer from 1st January 2019 
to 30th September 2023. After 2020, we observe 
increased numbers of diagnoses (Figure 1), radical 
nephrectomies (Figure 3), partial nephrectomies 
(Figure 4) and thermal ablations (Figure 5), along 
with a significant increase in SACT utilisation in the 
first quarter of 2023 following its approval by NICE 
for adjuvant therapy (Figure 6). For all of the graphs 
throughout this report Q1 is Jan-Mar, Q2 is Apr-Jun, 
Q3 is Jul-Sept and Q4 is Oct-Dec. Please note, the 
y-axes in the below graphs have different scales.
Figure 1. Diagnosis per quarter year in England
0
600
1200
1800
2400
Number of patients
Q1 2019
Q1 2020
Q1 2021
Q1 2022
Q1 2023
Quarter
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
Figure 2. Renal biopsies per quarter year in England
0
100
200
300
400
500
600
Number of patients
Q1 2019
Q1 2020
Q1 2021
Q1 2022
Q1 2023
Quarter
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
Figure 3. Radical nephrectomies per quarter year in England
0
200
400
600
800
1000
Number of patients
Q1 2019
Q1 2020
Q1 2021
Q1 2022
Q1 2023
Quarter
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
Figure 4. Partial nephrectomies per quarter year in England
0
100
200
300
400
Number of patients
Q1 2019
Q1 2020
Q1 2021
Q1 2022
Q1 2023
Quarter
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
Figure 5. Thermal ablations per quarter year in England
0
20
40
60
80
100
Number of patients
Q1 2019
Q1 2020
Q1 2021
Q1 2022
Q1 2023
Quarter
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
Figure 6. SACT started per quarter year in England
0
100
200
300
400
500
600
Number of patients
Q1 2019
Q1 2020
Q1 2021
Q1 2022
Q1 2023
Quarter
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021

Copyright © 2024 Healthcare Quality Improvement Partnership (HQIP)
14
Figure 7. Surgical approach for radical nephrectomies in 
England 2019-2023
25
0
50
75
100
Percentage of patients
2019
2020
2021
2022
2023
Open
Laparoscopic
Robotic
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
Figure 8. Surgical approach for partial nephrectomies in 
England 2019-2023
25
0
50
75
100
Percentage of patients
2019
2020
2021
2022
2023
Open
Laparoscopic
Robotic
Data were impacted by the COVID-19 pandemic and so will be atypical to some 
degree during 2020-2021
From 1st January 2019 to 30th September 2023, there 
has been an ongoing transition to robot-assisted 
radical nephrectomy, with more than a quarter of 
procedures taking place robotically in 2023 (Figure 7). 
This is mainly associated with a decline in the number 
of laparoscopic radical nephrectomies (Figure 7). In 
addition, most partial nephrectomies are now being 
performed as robot-assisted procedures (Figure 8).

Copyright © 2024 Healthcare Quality Improvement Partnership (HQIP)
15
4.1	 Data completeness and patient 
characteristics
Results for Wales were derived using Cancer 
Network Information System Cymru (CaNISC) 
datasets. The analysis included 490 people 
diagnosed with kidney cancer in 2022 (Table 3). 
NHS Wales is undergoing implementation of a new 
cancer informatics system. This implementation has 
affected the data quality and completeness for 
Wales in this audit. Data has not been clinically 
validated before submission to the audit.
The levels of completeness for the 490 people 
(Table 3) analysed were: 74% for T, 67% for N and 
64% for M category of stage. 76% of stage 
grouping (1-4) data was complete. Particular 
attention should be given to data reflecting T1a and 
T1b staging, as we were unable to include 
‘percentage of people with a small renal mass 
(≤4cm) who have a biopsy’ and ‘percentage of 
people with T1aN0M0 RCC who undergo nephron 
sparing treatment’ due to poor T1a and T1b 
differentiation. In addition, completeness of 
performance status (70% complete), sex (98% 
complete) and ethnicity (58% complete) data items 
could also be improved.
The median age at diagnosis was 70 years overall 
(IQR 60-78). There were more male people with 
kidney cancer than female, with 65% being male 
and 35% female. The percentage of people with a 
T1-2 stage was 61%. 16% of people had nodal 
disease (N1) and 21% had metastatic disease (M1). 
277 (97%) people being from the white ethnic 
group, of those known.
4.	 Results for Wales (2022) 
Table 3. Performance indicators for people with kidney cancer diagnosed and treated in Wales in 2022
National 
percentage 
%
Median %
(IQR %)
[range %; Health Board n]
No. of people 
with kidney 
cancer (total)
No. of events
PI1: Percentage of people with kidney 
cancer with the data completeness measure 
recorded for MDT meeting
99%
100%
(98-100%)
[97-100%; n=6]
490
486
PI5: Percentage of people with T2-3NxM0 
RCC** who have surgery 1 month prior and 
12 months following diagnosis
80%
79%
(69-85%)
[67-100%; n=5]
107
86
PI7: Percentage of people with metastatic 
RCC receiving initial SACT within 12 months 
of diagnosis
57%
66%
(50-78%)
[43-100%; n=6]
67
38
PI8: Percentage of people with kidney cancer 
who die within 30 days of SACT treatment
3%
0%
(0-7%)
[0-8%; n=6]
59
2
IQR: Interquartile range; MDT: multi-disciplinary team; RCC: renal cell carcinoma; SACT: systemic anti-cancer therapy. All numbers in this table are unadjusted. We have 
included median and IQR as these offer a better representation of skewed, non-normal distributions than mean (standard deviation). 
*Due to poor T1a and T1b differentiation, we could not include T1b patients in this performance indicator for Wales.
4.2	 Performance indicators
T2-3NxM0 RCC
Tumour is more than 7cm in size or tumour extends into major veins or perinephric 
tissues with no distant metastasis
** UICC TNM8 Kidney Cancer

Copyright © 2024 Healthcare Quality Improvement Partnership (HQIP)
16
Treatment planning
Key message: 99% of people diagnosed with 
kidney cancer in Wales In 2022 were recorded 
to have been discussed at an MDT meeting, 
with a health board IQR of 98% - 100% (Table 3). 
The Welsh health boards should maintain their 
current high standards of data completeness for 
whether people diagnosed with kidney cancer 
were discussed at MDT meetings.
82% of people diagnosed with kidney cancer 
(23,210 patients) between 1st January 2019 and 
31st December 2021 in England were recorded to 
have been discussed at an MDT meeting, with an 
NHS trust-level interquartile (IQR) of 74-92%. During 
this period, only 2% (352 patients) were recorded to 
have consented to a clinical trial with an NHS trust-
level IQR of 0 - 3%. 
There were only 4 cases where an MDT meeting 
was not recorded. This is currently surpassing the 
Scottish QPI4 MDT target of 95%. This is in line 
with the guidelines of the Welsh government for 
managing people on the suspected cancer pathway, 
where clinicians should collaborate as a multi-
disciplinary team in patient management.
Curative treatment for renal cell carcinoma
Key message: In Wales, 79% of people with T2-
3NxM0 RCC (86 patients) had surgery within 1 
month prior and 12 months following diagnosis 
in 2022. The median was 79% and the IQR was 
69 - 85% (Table 3). The Welsh health boards 
should increase the percentage of curative 
treatment for people with T2-3NxM0 RCC.
This aligns with the NHS Wales Cancer Improvement 
Plan for 2023-2026 to treat cancer effectively.
Systemic anticancer therapy for metastatic renal 
cell carcinoma
Key messages: In Wales, 57% of people 
with metastatic RCC (38 patients) received 
initial SACT, with a median of 66% and an 
IQR of 50 – 78% in 2022. 3% of people with 
kidney cancer died within 30 days of SACT 
treatment. The median being 0% with an IQR 
of 0 – 7% (Table 3). The Welsh health boards 
should increase timely access to SACT, while 
reducing severe associated toxicity.
NHS Wales Cancer Improvement Plan for 2023-2026 
emphasises the significance of Systemic Anti-
Cancer Therapy (SACT) in improving cancer survival 
and quality of life.
4.3	 National picture of kidney cancer 
treatment in 2022
Using CaNISC datasets, Figures 9 and 10 describe 
national patterns of treatment for kidney cancer 
from 1st January 2022 to 31st December 2022. 
We observe that 205 of 490 (42%) people with 
kidney cancer had renal biopsies (Figure 9), with 
51% of partial nephrectomies performed as open 
procedures (Figure 10).
Figure 9. Number of people with kidney cancer who received 
renal biopsies and different treatment options
0
50
100
150
200
Number of patients
Thermal ablations
Renal biopsies
Radical nephrectomies
Systemic therapy
Partial nephrectomies
Figure 10. Surgical approach for radical and partial 
nephrectomies
25
0
50
75
100
Radical nephrectomies
Partial nephrectomies
Open
Laparoscopic
Robotic
Percentage of surgeries

Copyright © 2024 Healthcare Quality Improvement Partnership (HQIP)
17
This first NKCA State of the Nation report 
provides a baseline description of the care 
delivered in NHS hospitals across England and 
Wales to people diagnosed with kidney cancer 
between 2017 and 2021. 
We report on indicators that were defined to monitor 
progress against the five NKCA healthcare QI goals: 
1.	 To increase the use of renal tumour biopsy 
2.	 To expedite treatment of people with potentially 
high risk for recurrence localised and locally 
advanced RCCs (i.e. cT3+, 10cm+, cN1 tumours) 
3.	 To increase use of surgery, if medically 
appropriate, for initially localised RCC at risk of 
progression 
4.	 To reduce the use of unnecessary extensive 
surgery for low-risk RCC 
5.	 To increase use of evidence based SACT 
treatment in eligible people with kidney cancer 
without severe toxicity
The performance indicators uphold principles of 
clinical relevance, methodological robustness, 
and technical rigor, fostering collaboration with 
data partners in England and Wales for continuous 
improvement and assessment. The audit is building 
on previous assessments of kidney cancer care 
in the UK and has drawn on these to develop the 
current eight performance indicators.
Clinical practice and its context can change over 
time, leading to changes in performance indicators. 
The NKCA’s goals and indicators are likely to evolve 
over time, and recommendations will become more 
focused as the NKCA learns through the audit and 
feedback cycle.
We have included the upper quartile of performance 
indicator values at the NHS trust (in England) 
or Health Board (in Wales) level. This is to help 
guide target thresholds; however, these figures 
were calculated without risk-adjustment and may 
be revised in future iterations of this report once 
risk-adjustment has been applied to understand 
appropriate target levels. 
Further indicators that we intend to introduce 
include the percentage of all people with kidney 
cancer who are treated within 31 days of a 
decision to treat (21 days of a decision to treat for 
Wales), the percentage of people with kidney 
cancer who are treated within 62 days of an 
urgent referral for suspected cancer, and the 
percentage of people with kidney cancer who 
have a biopsy to confirm histological diagnosis 
before non-surgical treatment. Treatment can 
include thermal ablation, surgery and SACT. These 
indicators have not been reported in this State of 
the Nation report due to the methodological 
development work required and time required to 
understand the nuances of the Cancer Waiting 
Times (CWT) dataset. The NKCA will also further 
develop its Quality Improvement Plan in 
collaboration with its stakeholders.
5.	 Commentary