Evolving Treatment Paradigms for Renal Cell Carcinoma - Episode 4

Risk Stratification for Metastatic Renal Cell Carcinoma


Daniel George, MD: During this section, we’re going to focus on some of the practical issues and factors that weigh into our decision on what therapy to start first for patients with metastatic renal cell carcinoma. I’m going to start first with risk stratification for metastatic renal cell carcinoma. Bob, do you want to walk us through a little bit of the models that we use and how you use them in practice?

Robert J. Amato, MD: Sure. The 2 main models that we’re presently using predominantly are the International RCC model to select patients and the Memorial Sloan Kettering model. Again, these have adapted over the course of years from focused more on cytokine therapy to now targeted therapy. I suspect immunotherapy may make a slight difference or a tweak, but the bottom line is performance status. If your performance status is 0, your prognosis is going to be better than if your performance status is 1, 2, and then of course 3 or 4. In selection for clinical trials, performance status is always going to be a key criterium. Criterium that has not gone away but has been discussed earlier: nephrectomy versus no nephrectomy. The influence of the kidney intact versus the kidney out, how long has the kidney been out, the history behind it relative to the metastatic presentation. Was it a year, 6 months? Was it 10 years? That’s going to vary in outcome as well.

I don’t think it should change the selection of agents unless one has a particular interest in a combination or a single agent, based on the data that’s in front of us and presented at ASCO 2018; whether you choose a TKI or a single-agent VEGF antibody versus combination checkpoint inhibitors, or single-agent checkpoint inhibitors. So, risk stratification, what other comorbidities exist. We know these drugs have cardiovascular issues that we have to pay attention to, and we have to work closely with a cardiovascular team. Especially, as Walt mentioned, when these patients go to the ER, they may not be going to the ER for their “cancer.” They’re going as a result of an arrhythmia or shortness of breath that has congestive heart failure. Then changes get made inappropriately, without discussion with the treating and planning oncologist. I absolutely agree with him, and it’s correct.

Each of these drugs has its own particular side effects that we have to be careful of. They’re manageable and to some degree can be reversible, but to some degree they’re not reversible. How we choose agents based on who is in front of us. You have a good prognostic patient, and they have various comorbidities that don’t allow us to select sunitinib or pazopanib. The challenge with sunitinib is, Which schedule is the best schedule to use now? Is it the 2-week-on schedule? Is it every other day? Is it the FDA approved 4/2?

Daniel George, MD: You bring up some great points, Bob. I’m going to stop you there because I think we want to get to a lot of these things, and you raised a lot of really important questions.

Transcript Edited for Clarity