Metastatic Renal Cell Carcinoma: Communicating Treatment Options With Patients

Shared insight on the treatment armamentarium for metastatic renal cell carcinoma and how these options should be communicated with patients.


Chung-Han Lee, MD, PhD: Thinking a little bit further for this patient, medical oncology was called as a consult in the setting, as they often are from the ED [emergency department]. A CT-guided biopsy was ordered, which did end up confirming clear cell renal cell carcinoma to the lung and then with lymph node metastases. Based off of some of those lab abnormalities that we see, the patient was deemed to be IMDC [International Metastatic RCC Database Consortium] poor risk, but relatively robust patient with a KPS [Karnofsky Performance Status] about 80%. Thinking about some of the treatments that we have from a kidney cancer perspective, there’s a lot of treatments in the frontline space. Multiple regimens have been developed and where we really do see things that have improved—overall survival and objective response rates—and have really changed the landscape for kidney cancer. Broadly, we see 3 types of medications. Medications tyrosine kinase inhibitors [TKIs], targeting angiogenesis pathways; mTOR targeted therapies, changing the metabolisms of the kidney cancer; and immunotherapies in which, at least in the frontline setting right now, we really are seeing 2 dominant approaches for kidney cancer. First of which is an IO [immuno-oncology] predominant approach in which you use 2 immunotherapies—the combination of ipilimumab [Yervoy] plus nivolumab [Opdivo], which demonstrated an improvement in objective response rate and overall survival compared to sunitinib [Sutent]. Then a TKI/IO sort of paradigm in which we use a combination of various tyrosine kinase inhibitors and anti-PD1 inhibitor which have demonstrated in across multiple studies improvements in objective response rate, progression-free survival, and also overall survival compared to TKI monotherapy. Certainly, multiple regimens have been approved including KEYNOTE-426, which is looking at axitinib [Inlyta] plus pembrolizumab [Keytruda]; the CheckMate 9ER study, which looked at cabozantinib [Cabometyx] plus nivolumab; also the CLEAR study, which looked at lenvatinib [Lenvima] plus pembrolizumab. All of which showing those 3 key metrics in which we’ve demonstrated increased efficacy. Patty, in thinking about some of the potential side effects, because side effects are clearly the opposite side and a key side to thinking about treatment options, how do you think about those types of side effects that can be associated with some of these treatments?

Patricia Fischer, Research Nurse: Well, thinking about immunotherapy drugs, their goal is to boost the immune system to fight the cancer. But at the same time, it will boost other systems within the body. That can have side effects of diarrhea perhaps, elevated liver function test values, sometimes itchy skin with or without a rash, as well as other organs can get affected throughout the body. But maybe those are some of the more common ones. Including the TKIs, their side effect profiles are typically elevating the blood pressure so we’d have to be sure to educate them about how to take their blood pressure using a battery-operated cuff for the arm. I like it when they bring it into clinic so we can compare it to a reading that we get just to make sure it’s similar and the machine is OK to use for them at home. We’d also have to talk to them about diarrhea and some of the precautions to help maintain regular bowel movements without diarrhea. And how to call us. How to reach us after hours as well as during hours if there’s a concern or a question.

Chung-Han Lee, MD, PhD: Thinking about ways to be proactive, right? You have that initial visit with the patient. There’s this overwhelming set of information that they’ve had in terms of the treatment plan and the potential side effects. What are ways that you’ve thought about to try to be proactively and preempting some of these issues that they may experience?

Patricia Fischer, Research Nurse: I like to use the fact cards that are available. Some institutions have their own. If not, the Kidney Cancer Association has a website that’s great and is a wealth of information for patients and caregivers. I think to start with the fact cards so that they have handwritten material. Even though I’m going to go over it in the room with them, it’s important to have something to bring home and they can use that to take notes on. I also want to give them a calendar to record, especially if they’re taking a drug by mouth every day or twice a day. I’d like to see that they record that on a daily basis. I’m also going to ask them to take a blood pressure at least once a day in the morning and record that on the calendar or the diary that they’ve taken their medication as well as their blood pressure. And discuss parameters with you as to when they should call us if they see a blood pressure above a certain number—what that number is, when to call us, and how to call us. Then we’ll see them in clinic to review these things. But I want them to know that they can call us as well.

Chung-Han Lee, MD, PhD: Certainly, blood pressure control is a huge issue, especially for this population that the medications are expected to raise people’s blood pressures and many of our patients are on multiple blood pressure medications already. What sort of advice do you give for the patients, because this is probably one of those side effects that they’re most responsible for?

Patricia Fischer, Research Nurse: Knowing what blood pressure medications they’re currently on with the correct dose and keep that up to date in their chart. Also have a discussion with you about what we might add if there’s a problem and give them the specific numbers to call us if there’s a concern. If they see this number, to give us a phone call.

Chung-Han Lee, MD, PhD: Certainly also, we of course want to mention to them if they’re actually symptomatic from their blood pressure, that’s going to be like incredibly important that they seek medical attention.

Patricia Fischer, Research Nurse: Right. They might think that the headache they’re having is just an ordinary headache or a headache from treatment, but it could be a sign of elevated blood pressure.

Chung-Han Lee, MD, PhD: Certainly we’ve always found that if we educate the patients in advance and let them know that these are possibilities that there’s probably a little bit less pushback when that call comes and says that you actually do have to seek medical attention.

Transcript edited for clarity.

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