The Impact of the Social Determinants of Health on a Patient with Renal Cell Cancer: A Case Report

Background

Renal cancer is the seventh most common cancer and 90% of cases are renal cell carcinoma (RCC). Symptoms of RCC may include hematuria, abdominal/flank pain, or fatigue, but over half of those with RCC are asymptomatic and diagnosed incidentally by an unrelated abdominal imaging study. Renal tumor size provides the greatest insight into a patient’s chance of survival. For every 1 cm increase in tumor size there is a 16% increase in malignant potential and masses greater than 7 cm have only a 7% chance of being benign. RCC has a 40% mortality rate that disproportionately affects those of low socioeconomic status (SES) who often present with larger and more advanced RCC. This correlation with low SES reflects decreased healthcare access and an increased prevalence of poor prognostic factors including obesity, hypertension, and hyperlipidemia. Additionally, patients without health insurance are 5.6% less likely to survive RCC.

Case Information

A 56-year-old Hispanic male first presented to a community clinic in Fort Worth, Texas in early 2017 for occasional fatigue and right flank pain that began in 2002. In addition to managing his hypertension, diabetes mellitus, and hyperlipidemia, the physician ordered an abdominal and pelvic CT that revealed a 5.4cm cystic and solid-enhancing right renal mass that was highly suspicious for RCC. Further disease progression was suggested with a 2019 ultrasound showing internal blood flow to the solid component of the mass and 2022 laboratory studies that revealed an elevated BUN (21 mg/dL), serum calcium (10.6 mg/dL), and ALT (56U/L). At the end of 2022, the patient brought in his latest CT report that he could not read because it was only provided in English. The CT revealed the 6.4cm x 4.1cm x 3.7cm mass and while medical translators communicated with the patient, differences in language may have impacted his understanding of his condition. For five years imaging and labs were performed repeatedly to monitor the large tumor, but treatment was never initiated because the patient believed he could not afford care without health insurance. The patient was referred to a local charity program for evaluation, but the program had a policy of not providing cancer treatment. The patient was encouraged to seek treatment in the local county health system, but he believed he could not afford treatment there or the expenses to relocate for treatment elsewhere. At this point, no further options exist for the patient.

Conclusions

Surgery would provide the greatest odds of survival for this patient, and ideally, it would have been performed before the mass reached such a concerning size. However, the patient believed he could not afford care without health coverage. With such a dismal prognosis, one can only speculate how the outcome would have changed if prompt medical care had been accessible to the patient. His financial resources, health coverage, language barrier, documentation status, and lifestyle all contributed to the unfavorable disease progression. This case serves as a single example of how social determinants of health continue to alter patient outcomes.