Advances and Challenges Faced in the Treatment of mRCC
Panelists: Daniel J. George, MD, Duke Cancer Center; Robert S. Alter, MD, Hackensack University Medical Center; Chung-Han Lee, MD, PhD, Memorial Sloan Kettering Center; Nizar M. Tamir, MD, FACP, The University of Texas MD Anderson Cancer Center
Daniel J. George, MD: Before we end the discussion, I’d like to get some just final thoughts from our panelists. Why don’t we just go around the counter here. Bob, do you want to start us off?
Robert S. Alter, MD: Sure. Taking care of these patients for the past 20 years, we went from our shrug shoulders, “Sorry, we can’t help you,” to “I’m not sure how to take care of this.” Then Nicholas Vogelzang wrote in the JCO [Journal of Clinical Oncology] editorial “The Embarrassment of Riches,” and I think everyone is talking that way—all the studies that we feel accomplished with, we feel as if we’re helping—but we’re not there yet. We are looking for everything—the biomarkers, the combinations, the sequencing—but until we have the answer, we are definitely at the mercy of our patients to help them better, have them be more exposed to clinical trials. The corroboration, as you mentioned before, about the community to the academics, is going to make us achieve that goal.
Chung-Han Lee, MD, PhD: Yes, these are truly exciting times that we’re in right now. With essentially new regimens coming out on a monthly basis and different mechanisms of actions coming into play, and this wealth of data, this is a dramatic difference from just a short while ago, and I think that this is all to the benefit of our patients. Like even this conversation about CR [complete response] was not a real conversation until just recently. We’re now seeing the progression-free survival in the first-line setting to over a year or year and a half, and things that used to be called a long-term survivor now are the median. I think this is all for the benefit of the patients, and there’s certainly a lot of work that needs to be done, but it’s a time to be really optimistic.
Daniel J. George, MD: I agree. Nizar?
Nizar M. Tannir, MD, FACP: It’s all good news for our patients. But in closing, I’d like to say that we really owe it to our patients. We really thank them and their healthcare providers for participating in these trials. We wouldn’t have all these exciting therapies now, and we won’t have more exciting therapies in the future and to cure. Because we really need to hope and aim for the cure, unless they participate in the trials, so we really thank them for that. I encourage other patients who do not participate and physicians who maybe do not refer patients for enrollment on trials, to do so because that’s the only way we’re going to make advances. As I tell my new patients I see in the clinic, when they come in with metastatic RCC [renal cell carcinoma], and I tell them I’ve been in this field 38 years, and 18 years of that have been at The University of Texas MD Anderson Cancer Center in academia, I tell them we have come a long way. Whereas in the past we really didn’t have many options, I tell them there is hope and we have a plan. I think this is good news for our patients, and I want them to think that we will break the barrier of cure in the near future—in our lifetime, before I retire.
Daniel J. George, MD: I think these are great thoughts. Not to be a little somber in this, but there’s still that 10% to 20% who are dying in a year even on clinical trials. In the real world, there are probably more who never make it to trial. I think we have some unfinished business to do. We have some unmet needs to fill. It’s important for us as clinicians to be able to recognize up front who’s at risk for dying from this disease early and make sure they get the best regimen. For the patients on the other end of the spectrum—who have low-volume disease, favorable-risk disease—it’s almost a different goal. It’s almost an opportunity to say how we can treat you now with a minimum amount of toxicity, how we can maintain your quality of life, how can we get you to CR with a combination of drug and surgery or drug and radiation in oligometastatic disease. A lot of different patterns and things to think about. There’s a huge spectrum in this disease, and I think it’s important. It’s incumbent on us to be able to know up front where our patient falls, have that goal-of-care discussion with them, and then begin to think about, with all these different options, including clinical trials, what’s the best path forward.
Nizar M. Tannir, MD, FACP: One final thought—if you allow me, Dan—we haven’t touched upon is really cost of our therapies. I’d like, and this is a plea to industry and us as a society, to bring the cost of therapies down. We cannot sustain. Unless we really bring the cost of drugs down, we won’t be able to treat all our patients. Think of how many patients in our society who are Americans do not have access, not just to clinical trials but to standard of care in inner cities and in rural America. Where I practiced in Kentucky, there are a lot of patients in the inner cities as well as rural America who don’t have health insurance. Or if they have health insurance, it’s not good enough to really cover their care. We really need to think of controlling healthcare costs—bring that from 18% down to be able to offer and cover all our patients, so that there is equality and justice in society.
Daniel J. George, MD: It’s created a cancer disparity for sure.
Nizar M. Tannir, MD, FACP: Definitely.
Daniel J. George, MD: It’s likely to widen with the expense of drugs getting further unless we have policy around that. Thank you for those thoughts, and really, thank you all for the contributions to this discussion. On behalf of our panel, we thank you for joining us, and we hope you found this Peer Exchange discussion to be useful and informative.