Choosing Which Patients Should Receive Adjuvant Therapy for RCC

Eric A. Singer, MD, MS, chief of the Division of Urologic Oncology, director of the Urologic Oncology Fellowship Program, and co-director of the Genitourinary Disease-Specific Research Group at the Ohio State University Comprehensive Cancer Center, and professor in the Department of Urology, Division of Bioethics at the Ohio State University College of Medicine, discusses which patients he believes would benefit most from adjuvant therapy for high-risk renal cell carcinoma (RCC).

There are data showing improvement of recurrence-free survival (RFS) with adjuvant therapy in patients with no evidence of disease (NED); however, there is no known overall survival (OS) benefit. Singer says he is cautious of using therapy if it does not extend OS or improve quality of life for patients. He discusses adjuvant therapy with patients who have high risk of recurrence based on characteristics used in the study criteria.

These characteristics include higher-grade sarcomatoid and rhabdoid features, larger and more aggressive tumors, and higher inferior vena cava thrombus. Singer says that node-positive disease classed as stage III was found to have similar outcomes to stage IV patients by researchers The University of Texas MD Anderson Cancer Center and should be considered at risk of recurrence. Patients with resectable synchronous metastases who receive surgery to remove the main tumor and metastases to the point of NED are also at high risk. Patients with these features are those who can benefit from adjuvant therapies including sunitinib (Sutent) and pembrolizumab (Keytruda).

TRANSCRIPTION:

0:08 | This is a patient who has NED on imaging and there's certainly a risk of recurrence. We have drugs that we know that change the RFS, but we don't yet know what that does to OS. One of the general principles of oncology is we have to be really careful. If it doesn't make you live longer, it doesn't make you live better or feel better, should we be doing it? I think we still need to answer some of those questions in the adjuvant RCC space. I tend to view the higher-risk patients as those who I would certainly have the conversation with everyone who's eligible based on these initial study criteria.

0:51 | But in my practice, I would say I lean certainly more towards those with higher grade sarcomatoid features, larger tumors, and certainly those with node-positive disease. [The University of Texas MD Anderson Cancer Center found], and then my group also validated their findings, that showed that the survival of node-positive RCC, even though it's grouped as stage III, have survival outcomes much similar to stage IV metastatic disease. I think node-positive disease; higher IVC thrombus; large, aggressive tumors with sarcomatoid or rhabdoid features; those are the ones that I think are most likely to benefit, as well as those patients with synchronous metastatic disease that's resectable. You could do cytoreductive surgery and metastasectomy to render them NED. [Those] are the highest risk groups that are most likely to benefit from these adjuvant therapies.