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Renal Cell Carcinoma: An Evolving Treatment Landscape

Panelists: Daniel George, MD, Duke Cancer Institute; Neeraj Agarwal, MD, Huntsman Cancer Institute; Robert Alter, MD, Hackensack University Medical Center; Bradley McGregor, MD, Dana-Farber Cancer Institute; Nicholas J. Vogelzang, MD, FASCO, FACP, Comprehensive Cancer Centers of Nevada
Published: Monday, May 07, 2018



Transcript: 

Daniel George, MD: This has been a great discussion. I think we’re super excited about the direction this field is going and the opportunities in this frontline space that are evolving with combinations of immunotherapy. The response rates seem to be going up and up. The progression-free survival seems to be getting longer and longer. Tolerance seems to be no worse than what we’ve seen. It’s an exciting time, and I’m optimistic we’re going to see further advances in our field. I’d like to just end with a few closing remarks from each of you. Neeraj, we’ll started with you. Why don’t you start us with some final thoughts?

Neeraj Agarwal, MD: This is really an embarrassment of riches, especially after moving forward 2 years from now, when we’ll add 5 different combinations including immunotherapy/immunotherapy and VEGF/immunotherapy. Maybe other ones will kick in, such as epacadostat with pembrolizumab. Maybe that will be approved. I think the most important and most pressing issue for us would be, at that time or even now, to look for biomarkers of response, to select patients who are going to respond or who are not going to respond, and to save on cost and toxicities. I think it’s very exciting overall, but I think that’s the most important issue now. Instead of just blindly picking drugs and randomizing them in clinical trials, I think we need to move towards picking up patients based on underlying biomarkers.

Daniel George, MD: Interesting. Bob, from the community, what are your thoughts?

Robert Alter, MD: I couldn’t agree more. Despite the fact that we’re just in a small community, we do have accessibility through our pathologists and lab means to definitely come up with these biomarkers. I think precision medicine is really meant to allow us now to try to find the right drug for the right patient at the right time. I think that if we can do that, our ultimate goal is patient care, quality of life, and survival. I think we may be able to do that soon enough.

Daniel George, MD: Brad?

Bradley McGregor, MD: I 100% agree with biomarkers. I think what’s most encouraging to me, as you saw in all these new data, is just the CR rates that we’re seeing. It’s something we never saw before. I meet a patient and I say, “With your disease, my goal is to treat you. I can’t cure you.” But maybe that’s not going to be the case, and maybe with these new therapies, we’re really going to get these long-term durable responses. I think these combinations are definitely going to be intriguing going forward.

Daniel George, MD: And Nick?

Nicholas J. Vogelzang, MD, FASCO, FACP: Well, I think we’re going to see more advances. We’re not done yet. With the triple combination of nivolumab/ipilimumab/cabozantinib, people are going to push the envelope. With the IDO inhibitors and the adenosine inhibitors, it may well be that in 2 years we’re going to be talking about an I-O, a TKI, and enhancing that TKI or enhancing that I-O. I’m looking forward to the next 5 years. We’re going to have 3-drug regimens that may well cure patients regularly.

Daniel George, MD: I think this is one of the key points for educational sessions like this and for the meetings that we have at ASCO GU. This is a field you need to stay up with. Kidney cancer is going to continue to evolve. We have more therapies than ever, but we also have new combinations and iterations of these agents. We have opportunities to get to no evidence of disease. In the adjuvant setting, we have an opportunity to treat now and keep patients from relapsing. We have clinical trials in that setting. We’re going to need community participants to help us to get those studies done.

In the frontline setting, you’re now going to see changes over the course of this year evolving into next year and probably the year after that. Keeping up with that, being early adapters, being open to trying new paradigms and approaches, looking for new endpoints, and trying to get to complete response are all the things that up until very recently we haven’t had the tools to really hope for, outside of the few exceptional responders.

Now, these are becoming 10% or 15% of the results in our clinical trials. These are legitimate endpoints that we can be shooting for. Our field is changing. There’s more hope than ever. It’s still daunting to take care of these aggressive patients who don’t respond, but more and more I think we’re seeing this disease become chronic and manageable. The more that you keep up with this with your patients or collaborate with your local academic centers in tumor boards, the more likely you’re going to see better results in your practice.

Transcript Edited for Clarity 

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Transcript: 

Daniel George, MD: This has been a great discussion. I think we’re super excited about the direction this field is going and the opportunities in this frontline space that are evolving with combinations of immunotherapy. The response rates seem to be going up and up. The progression-free survival seems to be getting longer and longer. Tolerance seems to be no worse than what we’ve seen. It’s an exciting time, and I’m optimistic we’re going to see further advances in our field. I’d like to just end with a few closing remarks from each of you. Neeraj, we’ll started with you. Why don’t you start us with some final thoughts?

Neeraj Agarwal, MD: This is really an embarrassment of riches, especially after moving forward 2 years from now, when we’ll add 5 different combinations including immunotherapy/immunotherapy and VEGF/immunotherapy. Maybe other ones will kick in, such as epacadostat with pembrolizumab. Maybe that will be approved. I think the most important and most pressing issue for us would be, at that time or even now, to look for biomarkers of response, to select patients who are going to respond or who are not going to respond, and to save on cost and toxicities. I think it’s very exciting overall, but I think that’s the most important issue now. Instead of just blindly picking drugs and randomizing them in clinical trials, I think we need to move towards picking up patients based on underlying biomarkers.

Daniel George, MD: Interesting. Bob, from the community, what are your thoughts?

Robert Alter, MD: I couldn’t agree more. Despite the fact that we’re just in a small community, we do have accessibility through our pathologists and lab means to definitely come up with these biomarkers. I think precision medicine is really meant to allow us now to try to find the right drug for the right patient at the right time. I think that if we can do that, our ultimate goal is patient care, quality of life, and survival. I think we may be able to do that soon enough.

Daniel George, MD: Brad?

Bradley McGregor, MD: I 100% agree with biomarkers. I think what’s most encouraging to me, as you saw in all these new data, is just the CR rates that we’re seeing. It’s something we never saw before. I meet a patient and I say, “With your disease, my goal is to treat you. I can’t cure you.” But maybe that’s not going to be the case, and maybe with these new therapies, we’re really going to get these long-term durable responses. I think these combinations are definitely going to be intriguing going forward.

Daniel George, MD: And Nick?

Nicholas J. Vogelzang, MD, FASCO, FACP: Well, I think we’re going to see more advances. We’re not done yet. With the triple combination of nivolumab/ipilimumab/cabozantinib, people are going to push the envelope. With the IDO inhibitors and the adenosine inhibitors, it may well be that in 2 years we’re going to be talking about an I-O, a TKI, and enhancing that TKI or enhancing that I-O. I’m looking forward to the next 5 years. We’re going to have 3-drug regimens that may well cure patients regularly.

Daniel George, MD: I think this is one of the key points for educational sessions like this and for the meetings that we have at ASCO GU. This is a field you need to stay up with. Kidney cancer is going to continue to evolve. We have more therapies than ever, but we also have new combinations and iterations of these agents. We have opportunities to get to no evidence of disease. In the adjuvant setting, we have an opportunity to treat now and keep patients from relapsing. We have clinical trials in that setting. We’re going to need community participants to help us to get those studies done.

In the frontline setting, you’re now going to see changes over the course of this year evolving into next year and probably the year after that. Keeping up with that, being early adapters, being open to trying new paradigms and approaches, looking for new endpoints, and trying to get to complete response are all the things that up until very recently we haven’t had the tools to really hope for, outside of the few exceptional responders.

Now, these are becoming 10% or 15% of the results in our clinical trials. These are legitimate endpoints that we can be shooting for. Our field is changing. There’s more hope than ever. It’s still daunting to take care of these aggressive patients who don’t respond, but more and more I think we’re seeing this disease become chronic and manageable. The more that you keep up with this with your patients or collaborate with your local academic centers in tumor boards, the more likely you’re going to see better results in your practice.

Transcript Edited for Clarity 
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