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In renal cell carcinoma (RCC), there are many variables to consider that can impact care, including medication costs, testing frequency, and management of treatment-related side effects. Brian Rini, MD, notes that the medication costs associated with targeted therapies can be a barrier for patients. When discussing treatment options, he educates the patient upfront on the costs. Although the drugs used in the treatment of RCC are very expensive, adds Daniel Heng, MD, they can effectively double overall survival.
When treating patients, Rini’s practice utilizes care paths, which include an examination of how care should be delivered and the appropriate frequency of tests. Rini notes that some tests are performed out of habit, and their frequent use is not necessarily evidence-based. It often takes 1 to 2 weeks to determine which therapy a patient will receive, which Rini says can be distressing for newly diagnosed patients, as they come to the office thinking they will be treated that day.
Heng, who practices in Canada, notes that first-line therapy in RCC is usually with a tyrosine kinase inhibitor (TKI), either pazopanib or sunitinib. Charles Henderson, MD, also uses pazopanib or sunitinib as first-line therapy. Selection of second-line agents depend on clinical circumstances, such as the duration and nature of response. For a patient with stable disease or response with a first-line TKI who then experiences disease progression after 8 to 12 months, Henderson prefers to try a second-line TKI, such as axitinib. If a patient’s disease progressed in a relatively short amount of time (≤ 4 months) while on a first-line TKI, Henderson considers everolimus as a second-line drug. Henderson adds that, in his opinion, the current RCC National Comprehensive Cancer Network treatment guidelines are overly broad.
When patients experience treatment-related side effects with a targeted therapy, many clinicians will adjust their dosing schedules rather than discontinue the medication, says Heng. For example, if patients cannot tolerate 50 mg of sunitinib, 4 weeks on, 2 weeks off, they may try 50 mg 2 weeks on, 1 week off, instead of undergoing a dose reduction or a switch in therapy. Heng mentions that an ongoing Canadian phase 2 clinical trial by principal investigator, Georg Bjarnason, is examining dose schedule individualization with sunitinib. In the study, dosing schedules are based on individual tolerability. Heng says there are very encouraging preliminary results, noting that individualizing dose schedules appears to improve outcomes when compared with historic controls.
Heng explains the importance of a healthcare team and their early involvement in a patient’s treatment to proactively manage problems. Heng says that the pharmacist’s role is somewhat different in Canada compared with the United States. Through an outpatient program, the pharmacist can reach out to patients to monitor and manage side effects. Similarly, nurse practitioners also help patients cope with their side effects.