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A Changing Landscape in RCC

Panelists:Robert A. Figlin, MD, FACP, Cedars-Sinai Medical Center;Daniel J. George, MD, Duke University Medical Center;Thomas Hutson, DO, PharmD, Baylor Charles A. Sammons Cancer Center;David F. McDermott, MD, Dana Farber Harvard Cancer Center;Elizabeth R. Plimack, MD, MS, Fox Chase Cancer Center;Nizar M. Tannir, MD, FACP, MD Anderson Cancer Center
Published Online: Friday, Sep 16, 2016



Transcript:

Robert A. Figlin, MD:
Dan, I’m sure our breast cancer colleagues dealt with this a decade or so ago. When you have a large number of options, many of which have different mechanisms of action, now we’re seeing longer-term survival, toxicities that could be chronic, and some toxicities with the IO agents that may require lifelong insulin replacement or steroid replacement. Many of the things that we never had to face a decade ago in kidney cancer, such as long-term toxicities, survivorship, and quality of life, how do we start to pivot to ask and answer those questions for our patients in a way that’s not really just agent-specific, but disease-generalizable?

Daniel J. George, MD: I think this is a great point. I’m glad you brought this up because this is something that’s starting to happen in a lot of cancer types, this concept of survivorship. And we typically think of it in terms of patients that are cured. But the reality is that these patients are survivors; they’re going to live, a proportion of them, 4, 5 years or more. And understanding that there’s a significant percentage of patients that are going to live that long, we need to start at the beginning with things like exercise, diet, and other kind of lifestyle modifications to really minimize the chronic deterioration that will happen, the deconditioning and complications of patients. We need to rehabilitate patients as we switch from one therapy on to another. We’ve been very passive, for the most part, in our field about either studying this or about really advising patients about this. It’s time we, as GU oncologists—probably you guys in the community do this a lot more than we do already, because you deal with these other cancers where this is already ingrained—need to start thinking about rehabilitating and reconditioning our patients. They do get hospitalizations, they get complications, they get skeletal events and other things. These are major setbacks, but there’s opportunity in these agents to improve.

David brought up the fact that quality of life improved, actually, for the first time in the CheckMate-025 trial, and that’s without any of this active instruction or intervention. If you actually intervene in this manner, you could probably make a much greater impact on those patients. And the survival benefit downstream of that could be dramatic. Because, it could allow for that extra line of therapy, or some other treatment effect, for them to tolerate that they might not otherwise tolerate, but could be a real life prolonging benefit.

I think it’s past time that we had the conversations up front. And we’re in a unique situation because we have very targeted therapies in this field. We don’t use generalized chemotherapy. We use VEGF-targeted therapy, which could have very specifically targeted effects on muscle, as well as vasculature, bone, and other things. I say that because there may be strategies that could really make an impact in a positive way.

Robert A. Figlin, MD: And I think, that for a recent article that was just in the Journal of Clinical Oncology, ASCO is trying to address this as they start to talk about the value of care. And the value-of-care initiative in cancer, in a more generalizable way, has been efficacy, toxicity, quality of life, and cost. One thing that we haven’t talked much about today, but I’m sure we will at a future meeting, is when you have 11 agents, soon to be more, maybe there are value conversations that need to take place to try and identify those things that are going to be different than the endpoints of a specific trial that get the survivorship, long-term toxicity, and the cost to society.

Transcript Edited for Clarity

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Transcript:

Robert A. Figlin, MD:
Dan, I’m sure our breast cancer colleagues dealt with this a decade or so ago. When you have a large number of options, many of which have different mechanisms of action, now we’re seeing longer-term survival, toxicities that could be chronic, and some toxicities with the IO agents that may require lifelong insulin replacement or steroid replacement. Many of the things that we never had to face a decade ago in kidney cancer, such as long-term toxicities, survivorship, and quality of life, how do we start to pivot to ask and answer those questions for our patients in a way that’s not really just agent-specific, but disease-generalizable?

Daniel J. George, MD: I think this is a great point. I’m glad you brought this up because this is something that’s starting to happen in a lot of cancer types, this concept of survivorship. And we typically think of it in terms of patients that are cured. But the reality is that these patients are survivors; they’re going to live, a proportion of them, 4, 5 years or more. And understanding that there’s a significant percentage of patients that are going to live that long, we need to start at the beginning with things like exercise, diet, and other kind of lifestyle modifications to really minimize the chronic deterioration that will happen, the deconditioning and complications of patients. We need to rehabilitate patients as we switch from one therapy on to another. We’ve been very passive, for the most part, in our field about either studying this or about really advising patients about this. It’s time we, as GU oncologists—probably you guys in the community do this a lot more than we do already, because you deal with these other cancers where this is already ingrained—need to start thinking about rehabilitating and reconditioning our patients. They do get hospitalizations, they get complications, they get skeletal events and other things. These are major setbacks, but there’s opportunity in these agents to improve.

David brought up the fact that quality of life improved, actually, for the first time in the CheckMate-025 trial, and that’s without any of this active instruction or intervention. If you actually intervene in this manner, you could probably make a much greater impact on those patients. And the survival benefit downstream of that could be dramatic. Because, it could allow for that extra line of therapy, or some other treatment effect, for them to tolerate that they might not otherwise tolerate, but could be a real life prolonging benefit.

I think it’s past time that we had the conversations up front. And we’re in a unique situation because we have very targeted therapies in this field. We don’t use generalized chemotherapy. We use VEGF-targeted therapy, which could have very specifically targeted effects on muscle, as well as vasculature, bone, and other things. I say that because there may be strategies that could really make an impact in a positive way.

Robert A. Figlin, MD: And I think, that for a recent article that was just in the Journal of Clinical Oncology, ASCO is trying to address this as they start to talk about the value of care. And the value-of-care initiative in cancer, in a more generalizable way, has been efficacy, toxicity, quality of life, and cost. One thing that we haven’t talked much about today, but I’m sure we will at a future meeting, is when you have 11 agents, soon to be more, maybe there are value conversations that need to take place to try and identify those things that are going to be different than the endpoints of a specific trial that get the survivorship, long-term toxicity, and the cost to society.

Transcript Edited for Clarity
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