Highlights from International Kidney Cancer Symposium, Chicago: Oct 25-26 2013
This meeting was hosted by the Kidney Cancer Association in the U.S., in joint sponsorship with the Cleveland Clinic. For further details about the meeting: www.Kidneycancersymposium.com Please note: this report is from my notes as a patient advocate attending on behalf of Kidney Cancer Canada.
I’ll begin my report with the ending: that researchers are as keen as we are to find a cure for kidney cancer – and in the meantime, to find optimum treatments that ensure a good quality of life for patients and their families. They need OUR help. They need patients to ASK about clinical trials and to enroll in studies whenever possible so that, together, we can move the research and the current practice forward – not just for ourselves as individual patients, but for kidney cancer patients around the world.
Here are some highlights from this two-day meeting:
Management of Small Renal Masses:
Cancer specialists have a “find it, fix it” mentality. In reality, physicians have become better at finding cancer early, but not necessarily better at improving outcomes. Cancer death rates haven’t been changing, but costs per incidence of cancer have nearly doubled. We need to ask: “should we fix it?” Managing cancer is about Managing Risk – we all manage risk all of the time. The challenge is to identify where surgery is highly beneficial — and where in fact in could be harmful.
One researcher classified renal cancers as “a lot of fish” – we need to figure out which are the minnows (benign), which are the non-aggressive sharks (indolent, slow growing cancers), and which are the man-eaters (aggressive cancers). Biopsy of a small renal mass can play a key role — is safe, 80% plus diagnostic, and can prevent the unnecessary resection of small benign masses. Active Surveillance can be an appropriate treatment for small, less aggressive renal cancers. Other less-invasive treatments can include ablation (not only RFA and Cryoablation, but also Microwave – hotter, faster. Will replace RFA).
Locally Advanced Disease:
In Europe, the guideline is to conduct a partial nephrectomy when a tumour is under 7 cm whenever technically feasible. For larger tumours, it all depends upon how much kidney tissue will be left behind. The surgeon’s goal is to save as many nephrons as possible to reduce likelihood of chronic kidney disease or cardiac complications later in life. (Many patients, especially older patients, run a higher risk of dying from causes other than their kidney cancer.)
Follow-up after locally advanced disease: most cancer relapses occur within 3 years, but patients also need to be followed for non-cancer related outcomes (e.g., hypertension, kidney function). Speaking of kidney function, a message from a nephrologist was to “stop talking about serum creatinine alone” saying that the single number (creatinine) was a poor indication of kidney function vs. GFR.
Sequencing of treatment: does the sequence of drugs matter? RECORD3 study proved that a TKI should be used before an mTOR. Beyond that, we don’t have data on sequencing. Dr. Janice Dutcher (NY) proposed a treatment algorithm that begins with assessing WHEN to start treatment (assess the urgency first) and then, in order of consideration:
- HD-IL2 (when appropriate)
- Immunotherapy trials (when possible) — look for trials that put immunotherapy first. These trials could include PD-1 inhibitors (Nivolumab) or CTLA-4 inhibitors (“Ippi”), especially in combination (together) or with other treatments.
- Other eligible trials
- Choice of TKIs, followed by mTOR inhibitors
Bone metastasis: one physician presented data on the impact of bisphosphonates for bone metastasis saying that the adverse events (hypocalcemia, renal insufficiency, ONJ) had been noted. In her review, the bisphosphonates (e.g., Zometa, Xgeva) did not improve Overall Survival, Progression Free Survival, or reduce SREs (skeletal related events – fractures, breaks). This report led to some healthy discussion and clearly there was some disagreement among clinicians. Some indicated that they use bisphosphonates for symptomatic bone mets only. All agreed that the best treatment for patients with bone mets is to treat and manage the underlying renal cell carcinoma well.
Interesting Clinical Trials Underway:
Much focus on 3 particular studies:
1. ADAPT Study: Phase 3, for newly diagnosed mrcc that is suitable for nephrectomy. Uses nephrectomy tissue to produce a personalized vaccine therapy.
2. METEOR Study: cabozantinib vs. everolimus. Theory is that resistance can be overcome by inhibition of Met + VEGFR. Will accrue 650 patients over 200 sites.
3. Nivolumab vs Everolimus. Requires tumour tissue available before randomization.
Question: how will we ever compare Nivo vs Cabo in the 2nd line? Will require a cross-trial comparison. Both trials are large, so it will be possible to do a sub-group analysis to see who does better and why. We need this data, so need these trials to accrue patients and allow this analysis to happen. The faster these trials finish accrual, the faster we will have the answers.
Much interest in using immunotherapy such as PD-1 (Nivo) much earlier – e.g., pre-operatively and post-operatively. For example, is there a role for immunotherapy immediately after nephrectomy? Immunotherapy is a powerful concept because the immune system is capable of building a memory to eradicate tumour cells if they arise in the future.
Call by Dr. Robert Figlin to kidney cancer researchers: “Time is short for all of us, especially for our patients – don’t think in terms of incrementalism… when you go to work and think about kidney cancer, keep your passion.”
As patients and caregivers, we couldn’t agree more. Thank you to the researchers who make our disease their priority. And thank you to the supporters of Kidney Cancer Canada who made it possible for me to attend on your behalf. If you can support the work we do, please consider a donation to keep the information flowing! www.kidneycancercanada.ca
Questions, comments, welcome!