Sumanta Kumar Pal, MD
As the fields of renal cell carcinoma (RCC) and bladder cancer continue to dramatically progress with the approval of novel agents—both immune-based and targeted therapies—oncologists need to improve their methods of selecting patients to receive such available therapies.
This point was made in a paper published in the Journal of Clinical Oncology
by Sumanta Kumar Pal, MD, who spoke to the ever-changing paradigm in bladder cancer and supported the recently released NCCN Bladder Cancer Guidelines, which advocate for molecular profiling in advanced bladder cancer. With greater use of genomic testing, Pal notes that patients will be guided to more rationale therapies and also be better selected to enroll on clinical trials.
In an interview with OncLive
, Pal, medical oncologist, assistant clinical professor, Department of Medical Oncology and Therapeutics Research, City of Hope, discusses advancements occurring in the treatment landscape of RCC and bladder cancer, the promise (yet caution) with immunotherapy, and guidelines that practitioners should use when choosing between immunotherapy and targeted agents for their individual patients. Pal lectured on this topic during the 2016 OncLive
State of the Science Summit on GU Cancer.
OncLive: What are some of the key issues right now with the available treatment approaches in renal cell carcinoma?
: In metastatic kidney cancer, there is a whole host of different treatment decisions that we need to make. In the first-line setting, there is a huge debate regarding whether or not interleukin-2 (IL-2) remains the standard of care. I would suggest that a lot of the data out there implicates that use of IL-2 is really waning. In contrast, we see a rise of trials that actually juxtapose VEGF inhibitors against novel immunotherapeutic strategies, and that likely represents the most en vogue approach right now.
You described IL-2 is waning in treatment. Why is that?
The big challenge with IL-2 is that, to date, we really haven’t developed objective criteria to pick appropriate patients. With some of the other drugs that we use in this category— VEGF inhibitors, for example—we tend to apply those across the board and across different study populations. The criteria that we are using now for picking patients with IL-2 remain somewhat arbitrary.
Are we researching ways to select patients better, or are we just moving on to different treatment methods?
My feeling is that that the new classes of therapy, the PD-1/PD-L1 inhibitors, may actually represent the new wave of agents that may potentially replace the approach of IL-2. IL-2 is not a particularly sophisticated approach. It really prompts generalized immune stimulation, whereas PD-1 and PD-L1 inhibitors can really promote immune stimulation in a much more organized fashion.
What are the latest updates with some of these newer agents?
As in many other cancers, what we’re seeing is that PD-1–based therapy has been introduced for renal cell carcinoma. Now, the agent nivolumab (Opdivo) is FDA approved for use in the second-line setting, following VEGF-directed therapies. What we’re probably going to see, in coming years, is incorporation of PD-1–based therapies in the frontline setting, but it will require clinical trials that compare these agents against VEGF-directed therapies. Those may mature over the next couple of years.
How do you approach your first-line patients?
Great question. In the context of first-line therapy for metastatic RCC, there are a number of different choices that are available. The NCCN guidelines, for instance, offer category 1 recommendations to agents such as sunitinib (Sutent), pazopanib (Votrient), bevacizumab (Avastin) with interferon, and temsirolimus (Torisel) in select cases.