“Big Advances”

Undoubtedly, the “big advance” in treating RCC has been immunotherapy, Dr Vaishampayan said.


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“Immune checkpoint inhibitors have rapidly become a means to establish long-term remission in patients with advanced kidney cancer,” she said. “We are also gradually fine-tuning what we considered routine therapy previously (nephrectomy for metastatic disease).”

Kidney cancer is “somewhat unique” compared to other cancers in that regard, Dr Vaishampayan said.

“Typically, once a solid tumor is metastatic it’s unusual to remove the primary,” she said. “But for kidney cancer we were still doing that based on randomized trial evidence that showed improved survival.”

When these data were published more than a decade ago, there were limited systemic therapeutic options — and those that were available were ineffective.

“Now that systemic therapy has remarkably improved accuracy, the need for surgery has dissipated somewhat. In fact, sometimes the surgery can stand in the way or delay the more effective systemic therapies that the patient needs,” Dr Vaishampayan said.

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An Ideal World

To truly create personalized management in advanced kidney cancer, “it will be critical to … [take] into consideration both tumor and patient characteristics to develop a tailored treatment plan,” the authors wrote.1 Using identified molecular markers as biomarkers, coupled with novel platforms such as circulating tumor DNA analysis, will continue to improve the possibilities for personalized medicine.

“In an ideal world, that is what you want,” Dr Vaishampayan said. “You want to be able to say to a patient, ‘This is the treatment for your specific tumor. With this treatment, you’ll have a good chance of responding.’ What we don’t want is to give shotgun treatments and hope it works in only about 10% of the patient population.”

At this point, however, these types of predictive treatment discussions are still preliminary, as “we are still fairly rudimentary in terms of biomarkers to help guide therapy,” Dr Vaishampayan said. “At this point, all we can really use are the validated clinical characteristics.”

Studies are ongoing that may overcome what Dr Vaishampayan says is “currently not validated data to decide therapy.”

“A single biomarker is not really going to be useful in kidney cancer,” Dr Vaishampayan explained. “Kidney cancer is too heterogeneous a disease. Finding one biomarker that defines treatment response is uncommon. We may see single-marker tumors in leukemia or hematologic malignancies, but in solid tumors, it is unlikely [single markers] will be the driving force.” A more realistic view is that there may be a panel of 10 to 20 genomic markers.

More likely than not, future treatment of kidney cancer will require “a combination of clinical and biologic approaches to fully realize the potential of precision oncology.”

References

  1. Graham J, Heng DYC, Brugarolas J, Vaishampayan U. Personalized management of advanced kidney cancer. Am Soc Clin Oncol Educ Book. 2018;38:330-341. doi: 10.1200/EDBK_201215
  2. Mejean A, Escudier B, Thezenas S, et al. CARMENA: Cytoreductive nephrectomy followed by sunitinib versus sunitinib alone in metastatic renal cell carcinoma—Results of a phase 3 noninferiority trial. J Clin Oncol. 2018:36: (suppl; abstr LBA3).