On the other hand, if immediate CN is the frontline treatment, it could delay systemic therapy, which is critical in patients with aggressive disease, because they are weak after surgery, Dr Bex said.

Researchers are also currently interested in exploring outcomes with immune checkpoint inhibitors (nivolumab and ipilimumab) in the context of CN, noted Dr Bex. The PROSPER RCC trial (ClinicalTrials.gov Identifier: NCT03055013) is under way, which will compare surgery alone with nivolumab prior to CN in patients with localized renal cell carcinoma.

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However, it is important to compare these treatments head-to-head in patients with metastatic disease, and there is 1 trial being considered in this population, Dr Haas said. Nevertheless, VEGF TKIs still have an important place in the treatment of mRCC because there is a large group of patients, particularly those with intermediate-risk disease, who respond better to VEGF TKIs than to immune checkpoint inhibitors, she pointed out.

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Ultimately, the avoidance of surgery is an important benefit to patients with metastatic cancer.

“In the era of modern drugs, there is no RCT [randomized controlled trial] evidence to suggest that patients [will] have better outcomes with surgery, and the only evidence [that does exist] suggests surgery may be safely avoided,” wrote Bishal Gyawali, MD, PhD, Brigham and Women’s Hospital, Boston, Massachusetts, in an email to Cancer Therapy Advisor. “The question of when to do a surgery ([which was the focus of] SURTIME) becomes relevant only when we know that surgery is useful.”

Disclosure: The SURTIME study was funded by Pfizer. For a full list of disclosures, please refer to the original study.


  1. 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 [published online December 13, 2018]. JAMA Oncol. doi: 10.1001/jamaoncol.2018.5543
  2. Méjean A, Ravaud A, Thezenas S, et al. Sunitinib alone or after nephrectomy in metastatic renal-cell carcinoma. N Engl J Med. 2018;379(5):417-427.