A novel risk score based on body mass index, monocyte-to-lymphocyte ratio, and the number and sites of metastasis could one day predict survival for metastatic renal cell carcinoma patients on immunotherapy, according to a December 2019 study in The Oncologist.1

Treatment options for metastatic renal cell carcinoma (mRCC) have changed radically with the advent of immunotherapies such asnivolumab, ipilimumab, and pembrolizumab. But with these newfound therapies comes the challenge of picking the best treatment for a given patient, says medical oncologist Bradley McGregor, MD, who was not involved in the study.

“At the end of the day, we are trying to give patients the most effective therapy,” said Dr McGregor, who is clinical director for Dana-Farber Cancer Institute’s Lank Center of Genitourinary Oncology. “We’re constantly looking for ways to discover who’s going to respond to therapy and who’s not going to respond.”

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The current gold standard for such discovery is the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) criteria.2 But the IMDC risk group criteria were first developed before the current age of immunotherapy, when anti-vascular endothelial growth factor (VEGF) therapy was the go-to mRCC treatment.

A team of Emory University researchers led by hematologist and medical oncologist Mehmet Asim Bilen, MD, set out to create a more up-to-date risk-scoring system. They retrospectively studied 100 patients with mRCC treated with immune checkpoint inhibitors from 2015 to 2018 at Emory’s Winship Cancer Institute. Roughly 70% of these patients were treated with anti–PD-1 monotherapy.

Using data collected at baseline, the team created a new 4-point score, dubbed the Emory risk-scoring system. The score adds 1 point each if patients have a monocyte-to-lymphocyte ratio (MLR) of 0.93 or above, body mass index below 24, and at least 2 metastases that are not found in the liver. Patients with fewer than 2 metastases had 0 points added to their score, and those with 2 or more metastases, including at least 1 in the liver, had 2 points added to their score.

“These factors are readily available and can be used clinically without additional cost,” wrote Dr Bilen, the study’s senior author, in an email to Cancer Therapy Advisor.

The team classified a score of 0 as good risk, 1 as intermediate, 2 as poor, and 3 or 4 as very poor. Poor-risk patients had significantly worse overall survival (hazard ratio [HR], 37.72; 95% CI, 4.76-298.70; P <.001) and progression-free survival (HR, 3.87; 95% CI, 1.50-9.96, P =.005) compared with good-risk patients. The team found similar trends for other pairings of lower- and higher-risk groups.

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Dr McGregor said he thinks the findings are an intriguing first step. But he cautions that the Emory team’s results are preliminary and that, at the moment, their risk score is not predictive.

“These data show that, using this prognostic marker, if you receive immunotherapy, [here’s] how you could be expected to do,” Dr McGregor said. “But that doesn’t necessarily say, ‘Oh, I should give you this immunotherapy instead of that.’”

Dr Bilen agrees that the findings require further validation. His team now plans to test its scoring system in a larger prospective study — a key step if providers are ever to use the score to help patients see how a particular immunotherapy regimen could work.

Disclosure:Study authors Mehmet Asim Bilen and Bradley Carthon have received funding from Bristol Myers-Squibb for research and travel, respectively.

The partner of Jonathan Wosen, who is the author of this summary article, is a Bristol Myers-Squibb employee.


  1. Martini DJ, Liu Y, Shabto JM, et al. Novel risk scoring system for patients with metastatic renal cell carcinoma treated with immune checkpoint inhibitors [published online December 5, 2019]. Oncologist. doi: 10.1634/theoncologist.2019-0578
  2. Ko, Jenny J., Xi, Wanling, et al. The International Metastatic Renal Cell Carcinoma Database Consortium model as a prognostic tool in patients with metastatic renal cell carcinoma previously treated with first-line targeted therapy: a population-based studyLancet Oncol. 2015;16(3):293-300.