Expert oncologists open their discussion on advanced clear cell RCC by identifying its prevalence and prognoses before moving into treatment considerations.
Thomas Powles, MD: Hello, and welcome to this OncLive® Peer Exchange® titled “The Evolving Treatment Landscape of Renal Carcinoma: Highlights from ESMO 2022 and Beyond.” I’m Tom Powles. I’m a professor of oncology at Barts Cancer Institute in London [England]. I’d like to introduce the rest of the panel. Eric, would you like to introduce yourself?
Eric Jonasch, MD: Hi, I’m Eric Jonasch. I’m at a professor of medicine at [The University of Texas] MD Anderson [Cancer Center in Houston, Texas].
Rana McKay, MD: I’m Rana McKay. I’m a professor of medicine at the UCSD [University of California San Diego School of Medicine in San Diego, California].
Ulka Nitin Vaishampayan, MD: I’m Ulka Vaishampayan. I’m a professor of medicine and oncology at the University of Michigan [Rogel Cancer Center].
Benjamin Maughan, MD: And I’m Ben Maughan, a professor of genitourinary oncology at the Huntsman Cancer Institute in Salt Lake City, Utah.
Thomas Powles, MD: We’re going to kick off this discussion with you, Ben. Can you talk about some of the background of renal cell cancer and some of the issues, perhaps around prevalence and bits around the disease?
Benjamin Maughan, MD: Renal cell carcinoma [RCC] is 1 of the more moderate, or somewhat less frequent, cancers in the United States. It’s about the ninth most frequent cancer that we see, but it’s not the most common cancer that oncologists are faced with in the clinic. As with every cancer, there’s a spectrum of biological activity and therefore prognosis for the patients that we see. Obviously, one distinction is: does the patient have metastatic disease vs localized disease? The treatment paradigms are quite divergent.
Thomas Powles, MD: Today we’ll predominantly focus on metastatic.
Benjamin Maughan, MD: Even in the metastatic situation, the biology in the spectrum is variable. We do have some clinical characteristics that we use to help guide or predict what the outcome is going to be for that patient. The 2 most common clinical criteria that we use are the Memorial Sloan Kettering [Cancer Center] or IMDC [International Metastatic RCC Database Consortium] scoring systems. The real bonus, or utility, of both systems is that they use very easy-to-obtain information, things like the hemoglobin or LDH [lactate dehydrogenase], or the time course of when they became metastatic, and you’re starting systemic therapy.
Thomas Powles, MD: Eric, why are we using calcium and not using biomarkers from a tissue?
Eric Jonasch, MD: That’s a good question. At this point, despite our best efforts, we haven’t found molecular biomarkers that are necessarily predictive for response. We’re evolving into demonstrating prognosis. For example, with a PBR1 mutation, the prognosis is probably better than with a BRCA1 mutation. But linking this to specific treatments and outcomes in specific treatments, at least in September 2022, we’re not quite there.
Thomas Powles, MD: Ben, when you look at the outcome of these patients, they come in and they’ve read about this group of new drugs, these immunotherapies. Many are expecting terrific results. What do you say to your patients when you meet them and they say, “What can I expect next in terms of my life expectancy?”
Benjamin Maughan, MD: That’s a great question. I share some of the enthusiasm that patients have because I remember treating some of these patients as an oncology pharmacist before I became a physician. At that time, we had interferon and high-dose IL-2, which most patients didn’t respond to. I’ve seen over time that transitioning from pharmacists to a physician dramatically improves. I share some of their optimism. They’ve had the duration of responses substantially improved, but the response rates have also dramatically increased. I share some of that enthusiasm, and that oftentimes comes out in my initial conversations with patients.
Thomas Powles, MD: What time you do your first CT scan and metastatic disease. Do you tell your patients at baseline what to expect? Or do you wait and say, “We’ll wait for the first response. If you respond, things are going to be OK. If they don’t, we’ve got a problem in our hands.”
Benjamin Maughan, MD: Typically, that first assessment, if there’s no significant new problems that have occurred during those first few months, I do it around 3 months. I usually take the tack of, “Let’s see what that response is, and then we’ll rediscuss where we’re going from there.”
Transcript edited for clarity.