Updates in Renal Cell Carcinoma Treatments

Sunitinib is effective in those categorized with favorable risk Renal Cell Carcinoma, according to a survey of the current research by Kinjal Parikh, PharmD, associate director of clinical strategy hematology/oncology for Medscape, at the 2019 Hematology/Oncology Pharmacy Association Annual Conference in Fort Worth, TX.

Renal cell carcinoma (RCC), according to Parikh, is the most common kidney cancer in adults, with a projected 73,820 new cases for the year 2019. Approximately 80% of RCC cases are of the clear cell histological type.  The survival rates for RCC are based on how advanced the disease is, but it is believed that 14,770 deaths will die due to RCC this year. Localized disease has the best prognostic outlook, with treatment options focused on resection. Advanced disease state incurs the worst prognosis and lowest five-year survival percentage.

The treatment options for advanced RCC are constantly changing due to the possibilities provided by systemic therapies, Parikh noted. The first-line recommendations for systemic therapy are based upon risk categorization based on the modified Memorial Sloan Kettering Cancer Center (MSKCC) criteria and/or scoring from the International Metastatic Renal Cell Database Consortium (IMDC). Both the modified MSKCC and IMDC predict survival in patients treated with systemic therapy based on clinical and lab data. These studies assessed the effect of different immunotherapies and combinations of immunotherapies based on patient risk stratification.

The patients included in the studies were diagnosed with metastatic clear cell renal carcinoma and (for the most part) had not been treated with any form of therapy. Overall, sunitinib (a vascular endothelial growth factor target) was found to be the most effective in favorable risk patients (categorization was based on IMDC when no prognostic factors are present), with a significant increase in objective response rate (ORR) and progression free survival (PFS). Quality of life (QOL) scores were also improved within the first six months in patients receiving sunitinib.

Moreover, combination immunotherapy was shown to be particularly effective in those without bone metastasis and is only currently FDA-approved for intermediate and poor risk patients. Programmed death-ligand 1 (PDL1) expression was analyzed due to its associated poor prognosis in those with RCC. A response to therapy was determined regardless of PDL1 expression, indicating prognostic rather than predictive usage.

The role of immunotherapy and combination immunotherapy is an active area of research with several investigative avenues, Parikh noted in his presentation. Some investigative points refer to the use of immunotherapy for early use in treatment, when to stop treating and use surveillance, and what therapy is ultimately the most effective in favorable risk patients. The role of PDL1 is still unclear in the ultimate treatment paradigm. It is evident that the continued research into other combinations will further re-shape accepted front-line treatments.

Parikh K. Updates in Renal Cell Carcinoma. Presented at the Hematology/Oncology Pharmacy Association Annual Conference; April 3-6, 2019; Fort Worth, TX.