Closing out their discussion on renal cell carcinoma, key opinion leaders highlight the value of multidisciplinary care and look toward future evolutions in the treatment paradigm.
Hans Hammers, MD, PhD: What other thoughts do you guys have as you look at how we manage patients at UT Southwestern Medical Center? How would you recommend to deliver effective therapy as a team and deliver therapy to patients? I know I use you 2 a lot. Quite frankly, my practice would be impossible without outstanding surgeons and radiation oncologists. I text you guys all the time and ask for your help. What are your thoughts how to best deliver care and what the future might hold?
Aurelie Garant, MD: It’s a very dynamic team we have here at UT Southwestern. We’re very blessed. Within the community, I think people ought to open those discussions up. We have emerging data justifying therapy for selected patients. Keeping the door open and the conversations going is very important. From a radiotherapy perspective, also interacting with your radiologists is important. If you don’t have an MRI [magnetic resonance imaging] scanner within the radiotherapy department, sometimes you can collaborate with your diagnostic radiology colleagues to request MRI time for some of these techniques, because you can get better soft tissue resolution and spine resolution, for example, in the case of [stereotactic body radiation therapy]. So [there is] definitely a different type of workflow in the community, but I think that in the end, patients benefit from having more options.
Vitaly Margulis, MD: For me, having direct and open lines of communication between all the providers really does translate into better outcomes. We have these conversations routinely. What do we do first? Why? When do we stop the systemic therapy? How do we consolidate? Having the tumor board presentation of these patients. All these things allow us to leverage better care.
Hans Hammers, MD, PhD: One more question. It’s not uncommon for me to see patients with large masses where the surgeon says, “Hey, why don’t you talk to this [individual] and see [whether] you can shrink your mass a little bit?” What is your personal practice for this, I would say, still an exploration neoadjuvant space? Let’s say if you look at data from Dr Axel Bex [PhD] with the neoadjuvant axitinib-avelumab [Inlyta/Bavencio]—I think you yourself have a clinical trial that looks at an imatinib-pembrolizumab [Gleevec/Keytruda], with trying to shrink those tumors even before surgery—what are your thoughts?
Vitaly Margulis, MD: We are now in the era where we have excellent response rates with these drugs, and they’re very well tolerated. From a surgical perspective, it’s really not the size of the tumor that makes a difficult or easy surgery. It’s things like, is there evidence of invasion into adjacent structures that is going to require multi-organ resection? We can shrink the tumor and allow for this to retract. Perhaps the patient can avoid colon resection or adjacent liver resection. This decreases the complexity and morbidity of the surgery. Similarly, the clinical trial we have with pembrolizumab-lenvatinib [Lenvima] addresses the situation of a cable tumor thrombus, right? So we know that the higher the tumor thrombus, the closer to the heart, the more complicated the surgery, higher blood loss, [and] higher morbidity to the patient. So can we leverage some of these drugs, some of these response rates, to really decrease the size of tumor thrombus and allow us for less complex resection? In some cases, we’ve converted patients from needing a big open chest surgery to avoiding a chest surgery. We have converted patients from an open, large incision to something that was now amenable to minimally invasive approach with [the use] of some of these drugs. My point is it’s not purely about the size of the tumor, it’s how the nuances go into it. These are very attractive strategies that we and others are actively exploring.
Hans Hammers, MD, PhD: Thank you so much. With that, I would like to thank my colleagues, Dr Margulis and Dr Garant, for this insightful discussion. And to our viewing audience, thank you for joining us. We hope you found the OncLive® Inside the Clinic program to be useful and valuable to your management of patients with renal cell carcinoma. Thank you so much.
Transcript edited for clarity.