Guidelines update: Bladder, kidney, prostate cancer
Recent statements reflect rapid pace of diagnostic, treatment advances
Immunotherapy for treatment of RCC (Society for Immunotherapy of Cancer)
A subset of patients with metastatic kidney cancer may not need immediate treatment, says Brian Rini, MD, medical oncologist at the Cleveland Clinic Taussig Cancer Institute and professor of medicine at the Cleveland Clinic Lerner College of Medicine. That point, along with recommendations on the use of newer immunotherapy agents and older drugs, is outlined in the Society for Immunotherapy of Cancer’s consensus statement on immunotherapy for the treatment of renal cell carcinoma (RCC), which was published last year in the Journal for ImmunoTherapy of Cancer (2016; 4:81).
Since clinicians are trying to provide patients with the most benefit with the least amount of risk, that sometimes means not treating RCC patients—or certainly not treating them immediately, says Dr. Rini, the consensus statement’s first author. This is the appropriate treatment approach for patients who have very indolent disease that’s not bothering them. An additional benefit of this approach is that sometimes simply watching patients for a period of time can delay side effects while not compromising the benefit of ultimate treatment, he adds.
While interferon-alpha and interleukin-2 have been used for decades with positive results, new immunotherapy agents for the treatment of renal cell carcinoma have been approved, according to the consensus statement. These new agents prevent tumor growth by preventing vascular endothelial growth factors in addition to tumor metabolism. Immune checkpoint inhibitors, the newest class of immunotherapy agents, should also have an impact on patients with RCC.
According to the consensus statement, observation or enrollment in a clinical trial based on Level A evidence for cytokines and Level A evidence from the ASSURE clinical trial are the most appropriate treatment paths for patients with resected stage II and III renal cell cancer. Members of the task force that developed the statement agreed that nephrectomy is an important component of managing patients with renal cell carcinoma; further, the resection of oligometastases is supported, but it’s unclear how novel immunotherapy could impact these surgical approaches.
There was division among task force members on the role of high-dose interleukin-2 in treating metastatic RCC. The overall opinion was that appropriate patients who have undergone a nephrectomy should discuss interleukin-2 with their clinicians and then receive a referral to a center of excellence for further discussion of treatment options. Sixty-seven percent of the experts agreed that a discussion about interleukin-2 was appropriate, while the remaining members said it was more appropriate for clinicians to select patients for these types of conversations.
In addition to outlining new therapeutic agents and different approaches to patients, and incorporating immunotherapy into the routine management of kidney cancer, which is only just starting, Dr. Rini says this guideline “is really setting the stage for what’s to come as much as it is about taking care of patients now.”