Panelists: Robert A. Figlin, MD, Cedars-Sinai Medical Center; Thai H. Ho, MD, PhD, Mayo Clinic Arizona; Martin H. Voss, MD, Memorial Sloan Kettering Cancer Center; Michael B. Atkins, MD, Georgetown Lombardi Comprehensive Cancer Center; Sandy Srinivas, MD, Stanford University Medical Center
Robert A. Figlin, MD: Sandy, as we’re talking about high-risk resected patients, for some patients, high-risk resected disease is not very far from early metastatic disease. We see a lot of patients with metastatic kidney cancer, and we’ve talked a little bit about using prognostic systems to help us identify who we would choose for what therapies. Before we get into a conversation about what therapies to choose, how do you evaluate the newly diagnosed metastatic patient? And, also, can you help me to understand where you think active surveillance might fit into that paradigm for some of those people?
Sandy Srinivas, MD: For a patient with newly diagnosed disease, when I sit in front of the patient, I think about, what’s the goal that we are hoping to accomplish in this patient? Is there minimum disease where, perhaps, you could give some systemic therapy or even just consider metastasectomy? I really start off by finding out what the goal that we are hoping to accomplish is. If you have a patient with widespread liver metastases and bone metastases, it’s unlikely that you can use that approach, so I think a goal is important.
Second, I think the performance status of the patient and age of patient has always been part of our decision making. If somebody is young and fit, we continue to give high-dose IL-2 [interleukin-2]. I’ll certainly bring that up, even though we have another immunotherapy that is less toxic. It’s temping. But, I think high-dose IL-2 continues to be part of their therapy. So, I think about age and I think about performance status.
And then, there are some known prognostic factors. I’ve really not used them to pick a therapy, but I think it’s helpful for a patient to put them in different buckets to help determine how they are likely to do and what their life expectancy could be.
Robert A. Figlin, MD: Thai, some of the patients that we see with metastatic disease don’t come to us after having a prior nephrectomy, they come to us with a primary tumor in place. And we now have more than a decade’s worth of data where we’ve integrated cytoreductive nephrectomy into our clinical practice. Yet, there really are not firm data about cytoreductive nephrectomy in the era of targeted therapy, prospectively. How do you navigate through, with your urologic oncology colleagues, decisions about when to leave the kidney in, or when to take it out, in the setting of metastatic disease?
Thai H. Ho, MD, PhD: I usually risk-stratify the patient based on some clinical criteria. I look at things like anemia, calcium, their level of platelets, neutrophils, and this gives me a sense of what their overall prognosis is going to be. And the other advantage, at least for cytoreductive nephrectomy, is that sometimes you can palliate the symptoms in a lot of patients who have a high tumor burden, and they may have some symptoms from that. The other advantage, I find, from cytoreductive nephrectomy, is that you get tissue—both therapeutic and diagnostic. In the past, people have shown overall survival benefit in patients with good and intermediate-risk kidney cancer. So, when I talk to the urologist, the goal of the cytoreductive nephrectomy is both palliation and the potential for overall survival; and also, getting diagnostic tissue.
Robert A. Figlin, MD: Would you say that most of your patients with primary tumors in place in metastatic disease undergo a cytoreductive nephrectomy?
Thai H. Ho, MD, PhD: If their performance status is good and they’re an operative candidate, they do.