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Renal Cell Carcinoma: Early Management Strategies

Insights From: Eric A. Jonasch, MD, MD Anderson Cancer Center; Elizabeth R. Plimack, MD, Fox Chase Cancer Center
Published: Friday, May 15, 2020



Transcript: 

Eric A. Jonasch, MD: There’s been a real evolution of the role of cytoreductive nephrectomy in metastatic renal cell carcinoma over the past decade-and-a-half. Initially, back in the cytokine era, we had data that suggested that cytoreductive nephrectomy improved outcome in individuals subsequentially treated with interferon. But most recently, we have several studies that have come out that suggest that at least in the context of patients treated with antiangiogenic therapy, cytoreductive nephrectomy does not actually improve outcome. There might be even a trend toward worse outcome. And so, for that reason at this point, we’re certainly less enthusiastic about advocating cytoreductive nephrectomy as an upfront strategy for individuals with metastatic renal cell carcinoma.

Elizabeth R. Plimack, MD: What’s really interesting about renal cell carcinoma, having treated it for so many years, is how different each patient’s disease is. Sometimes when we meet a patient for the first time, we’re not sure what the character of their cancer will be. There are some patients whose cancer grows so slowly that really, we aren’t going to gain them anything by starting treatment. As I tell the patient, “If you were on a drug right now, we’d be giving the drug credit for controlling your cancer, but you’re doing it on your own.” And that’s a group of patients who I think all of us favor observation or surveillance for. We know they have cancer. We can see it on the scan. It’s so small. They’re not going to get a symptom from it. They don’t have any symptoms from it, and scan to scan there’s no growth or minimal growth.

The advantage to surveillance is severalfold. They don’t have adverse effects of treatment. They don’t have to come to the center for infusions. Convenience wise, cost wise, and quality of life wise, it’s better. But as I tell my patients under surveillance also, the longer we can wait before we treat you, the more time it gives us as a research community to invent something better and to get something better for them. And so that when it is time for treatment, I hope that we’ll have something even better than we have now. And that really resonates with patients. It’s hard to know you have cancer and you’re not treating it. People want to do something, and we hear that a lot. But it’s a marathon, not a sprint. There’s strategy involved, and surveillance is a really important part of that strategy for the right patient.

Eric A. Jonasch, MD: One of the other interesting questions in patients with renal cell carcinoma is, do you have to treat a person who has metastatic disease? You may have an individual who has a small number of metastatic lesions or small volume disease, they’re completely asymptomatic, and you have evidence that this disease is not growing very quickly. There are some phase II studies that have been done showing that it’s OK to wait before initiating systemic therapy in these patients. And it doesn’t, at least compared to historic controls, seem to really decrease their survival or their outcomes. The rate of change of lesions will define whether you need to initiate therapy as well as the burden of disease up front.

Transcript Edited for Clarity
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Transcript: 

Eric A. Jonasch, MD: There’s been a real evolution of the role of cytoreductive nephrectomy in metastatic renal cell carcinoma over the past decade-and-a-half. Initially, back in the cytokine era, we had data that suggested that cytoreductive nephrectomy improved outcome in individuals subsequentially treated with interferon. But most recently, we have several studies that have come out that suggest that at least in the context of patients treated with antiangiogenic therapy, cytoreductive nephrectomy does not actually improve outcome. There might be even a trend toward worse outcome. And so, for that reason at this point, we’re certainly less enthusiastic about advocating cytoreductive nephrectomy as an upfront strategy for individuals with metastatic renal cell carcinoma.

Elizabeth R. Plimack, MD: What’s really interesting about renal cell carcinoma, having treated it for so many years, is how different each patient’s disease is. Sometimes when we meet a patient for the first time, we’re not sure what the character of their cancer will be. There are some patients whose cancer grows so slowly that really, we aren’t going to gain them anything by starting treatment. As I tell the patient, “If you were on a drug right now, we’d be giving the drug credit for controlling your cancer, but you’re doing it on your own.” And that’s a group of patients who I think all of us favor observation or surveillance for. We know they have cancer. We can see it on the scan. It’s so small. They’re not going to get a symptom from it. They don’t have any symptoms from it, and scan to scan there’s no growth or minimal growth.

The advantage to surveillance is severalfold. They don’t have adverse effects of treatment. They don’t have to come to the center for infusions. Convenience wise, cost wise, and quality of life wise, it’s better. But as I tell my patients under surveillance also, the longer we can wait before we treat you, the more time it gives us as a research community to invent something better and to get something better for them. And so that when it is time for treatment, I hope that we’ll have something even better than we have now. And that really resonates with patients. It’s hard to know you have cancer and you’re not treating it. People want to do something, and we hear that a lot. But it’s a marathon, not a sprint. There’s strategy involved, and surveillance is a really important part of that strategy for the right patient.

Eric A. Jonasch, MD: One of the other interesting questions in patients with renal cell carcinoma is, do you have to treat a person who has metastatic disease? You may have an individual who has a small number of metastatic lesions or small volume disease, they’re completely asymptomatic, and you have evidence that this disease is not growing very quickly. There are some phase II studies that have been done showing that it’s OK to wait before initiating systemic therapy in these patients. And it doesn’t, at least compared to historic controls, seem to really decrease their survival or their outcomes. The rate of change of lesions will define whether you need to initiate therapy as well as the burden of disease up front.

Transcript Edited for Clarity
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