Welcome to summer in Canada!
As Director of Medical Relations for Kidney Cancer Canada, I have just returned from St. John’s, Newfoundland where I attended the Canadian Urological Association (CUA) Conference. During my visit, a friendly local asked me if I was in town “for that Urine conference”? Indeed, there were 800 of us in town studying the latest in Urology including urological cancers — prostate, bladder, testes, and kidney. I had the opportunity to attend many of the sessions for Kidney Cancer Canada, along with our new Board Chair, Dr. Ross Klein who just happens to live in the beautiful city of St. John’s.
Attending conferences like the CUA means learning a lot, and bringing back a ton of ideas for how we can help patients and their families. We also take the opportunity to meet new (and old) urologists and let them know about our organizations for patients:
Here are some of the medical highlights from sessions relating to kidney cancer. Please note that these are written from a patient perspective. As always, if you have questions about your own case, please ask your urologist or oncologist.
Role of Biopsy in Renal Cell Carcinoma for Small Renal Masses
Dr. Tony Finelli (UHN) suggested that it is time to shift the current paradigm towards more routine biopsy for small renal masses. He cited that biopsies have proven diagnostic in 90% of cases (n=476). Biopsies have been 100% accurate in determining benign from malignant tumours; and about 65% concordant with final grade and subtype of tumour. Some discussion about minimum size to biopsy (not worthwhile if less than 1 cm).
Overall, the goal here is to reduce the frequency of surgeries for patients who have a suspicious mass that turns out to be benign and/or appropriate for active surveillance. (In the past, up to 20% of suspicious masses removed have turned out to be benign. While it’s great to hear the “good news” that a tumour is benign, it’s better to hear that before you lose part or all of a healthy kidney that you might need later in life.) Risks of renal biopsy are extremely minimal — should be discussed, but new techniques make the procedure safe and useful for expert management of smaller tumours.
Presentations from CKCIS (Canadian Kidney Cancer Information System)
Many presentations drew data from CKCIS, now accumulating data from 15 centres from 6 provinces across Canada. This data is proving extremely worthwhile to understand real-world treatment decisions, outcomes, and trends. For example, Dr. Karim Marzouk (Halifax, NS) reported on recurrence after “curative surgery” citing that 73% of recurrences had been diagnosed by routine imaging (very few were symptomatic). Tumour size and presence of sarcomatoid features were the only significant predictors for recurrence rates. (Message to patients here is to maintain your vigilance with regular surveillance per the CUA Guidelines for Follow Up after Nephrectomy — speaking of which, these guidelines were just updated this month and can be found here, by Dr. Ricardo Rendon et al.
Note: If you’ve made a donation to KCC, pat yourself on the back — your donations have gone to support this great “information system” that will continue to shape the future of kidney cancer treatment in Canada and beyond. We are hoping to fund new projects using this great information resource. If you can help with a donation, please take a moment to do so. To donate online, click here.
What is the Role for Nephrectomy in the Presence of Metastatic Disease?
Approximately 25% of kidney cancer patients are diagnosed from the outset with stage IV or metastatic disease. Dr. Rod Breau (Ottawa) discussed data showing the prevalence of nephrectomy is decreasing among patients with metastatic disease. In the past, data showed some benefit in removing the kidney mass (possibly through decreased immune suppression). However, rationale for cyto-reductive nephrectomy has changed in the era of targeted treatments. A clinical trial (SURTIME) is recruiting patients so that we can better answer how to treat patients who are already metastatic at time of diagnosis. Patients will either have a nephrectomy then sunitinib, or sunitinib first, then nephrectomy, then back on sunitinib. Another trial testing one of the new PD-1 drugs before nephrectomy will be up and running in Canada before the end of 2014.
Other ideas presented for decision-making were to look at the total volume of tumour and proceed if the surgery could remove 90% of the tumour volume. Also suggested to look at the Heng Criteria (if over 3 criteria present, advisable not to do surgery), and also the patient’s age if over 75 years due to higher risks of surgery.
Future of Oncology & Treatment Based on Molecular Profiling
Dr. Phil Bedard (PMH) presented some of the progress being made towards identifying mutations across many types of cancers noting that the same genes are seen in different tumour types. Two major clinical trials are underway and recruiting patients (IMPACT and COMPACT). Both are molecular profiling trials. IMPACT is available to UHN patients, but COMPACT is open to patients from other community hospitals (but does require one visit for enrollment, blood, genetics discussion). About 1600 patients are currently enrolled with only 80 of those from the “GU” cancers to date. Patients can ask about these trials if they have: advanced disease, good performance status, and “tissue available” somewhere (does not require fresh tissue).
Discussion centered around what can be done with the “omic” data – in some cases, the data has suggested a treatment pathway that might not have been considered otherwise. Heads-up for the future that this might mean treating kidney cancer with “another-type-of-cancer” drug – which of course brings its own access issues. In the short term, these trials are worth asking your oncologist about.
Thank you to our fantastic medical community who were in sessions right up to and including Canada Day. We are privileged to have such a dedicated team working on kidney cancer and committed to moving the field forward, not just in Canada, but across the world.
And lastly, just so you know that urologists really are a fun bunch of people, here’s a shot from the all-Urologist band called “The Void” playing some amazing music… but let’s hope they keep their day jobs too.