Consider Patient Factors Before Determining RCC Treatment

As more options become available, there are some important patient characteristics to consider when determining a treatment plan for someone with renal cell carcinoma (RCC), explained Kelvin Alexander Moses, MD, PhD.

Moses, an associate professor of urology in the Department of Urology at Vanderbilt University Medical Center, recently spoke with OncLive, a sister publication of Oncology Nursing News, about how practitioners should decide if a patient with RCC should undergo cytoreductive nephrectomy — which has been standard of care for more than 2 decades – or systemic therapy.

“For a long time, the topic of cytoreductive nephrectomy was thought to be fixed in stone. In the 1990s and early 2000s—the interleukin-2 era—studies showed that patients who had upfront cytoreductive nephrectomy had a survival benefit. Now, investigators want to see if that survival benefit still exists [in this era of] targeted therapy, TKIs, and checkpoint inhibitors,” Moses said.

CARMENA and SURTIME Trials

The phase III CARMENA trial suggested that treatment with single-agent sunitinib (Sutent) may lead to improved overall survival (OS) rates than cytoreductive nephrectomy/sunitinib¹.

The phase III SURTIME trial showed improved average OS for patients who deferred cytoreductive nephrectomy until after systemic therapy with sunitinib compared to those who underwent surgery immediately.²

“If you give systemic therapy upfront [with sunitinib] and there is no progression, then cytoreductive nephrectomy is certainly an option,” Moses said.

However, the trial did not meet its accrual goal — an important note to consider when analyzing its results.

Factors to Consider in Treatment Decision Making

Moses said he considers the following when deciding if a patient should undergo cytoreductive nephrectomy:

• Patient’s overall health status
• Metastatic disease
• Site of metastatic disease
• Local symptoms
• Performance status

He explained that patients with a larger metastatic burden are more likely to receive systemic therapy first.

“If they have a response or disease regression, and the primary site is now the greatest burden of disease and the patient has done well otherwise, I will consider a cytoreductive nephrectomy,” he said.

Next Steps

There is still more research to be done when it comes to determining the best treatment options for patients with RCC, Moses said.

In fact, the PROSPER trial is now accruing. It’s examining perioperative nivolumab (Opdivo) versus observation in patients with localized disease undergoing cytoreductive nephrectomy. 

Additionally, there are still questions that remain unanswered regarding cytoreductive nephrectomy and who is best fit for the procedure.

“We don't know how to pick the right patients for cytoreductive nephrectomy yet. A significant portion of the patients in the trials done so far have been poor-risk. If a patient presents with metastatic disease, they can't be good-risk,” he said. “Could good- or intermediate-risk patients benefit from cytoreductive nephrectomy? That still needs to be teased out.”

References

• Mejean A, Ravaud A, Thezenas S, et al. Sunitinib alone or after nephrectomy in metastatic renal cell carcinoma. N Engl J Med. 2018;379:417-427. doi: 10.1056/NEJMoa1803675.
• Bex A, Mulders P, Jewett M, et al. Comparison of immediate vs deferred cytoreductive nephrectomy in patients with synchronous metastatic renal cell carcinoma receiving sunitinib: The SURTIME randomized clinical trial. JAMA Oncol. 2019;5(2):164-170. doi: 10.1001/jamaoncol.2018.5543.

A version of this article originally appeared on OncLive as, “Patient Factors Critical to Treatment Selection in Prostate Cancer, RCC.”