Evidence-Based Strategies to Improve Outcomes in Advanced RCC - Episode 7
Comprehensive discussion on how to best treat patients with renal cell carcinoma and brain or bone metastasis.
Robert J. Motzer, MD: Bob, quality of life is important in a general sense for patients on treatment. There have been various publications looking at quality of life with ipilimumab-nivolumab compared with sunitinib-cabozantinib-nivolumab compared with sunitinib, and the presentation of lenvatinib-pembrolizumab vs sunitinib. What’s your take in terms of these analyses? Is this something that you feel translates or influences your own practice?
Robert S. Alter, MD: Very much so. As you mentioned, Dave Cella and you at the last ASCO [American Society of Clinical Oncology Annual Meeting] presented data on quality-of-life measures, whether it’s going to be [the Functional Assessment of Cancer Therapy]–Kidney Symptom Index or EORTC [European Organisation for Research and Treatment of Cancer]. These measures resonate to us the importance of treating not only the disease but also the patient. From CheckMate 214, Dave Cella did a supplement of a presentation 2 years ago talking about the benefits of quality-of-life measures. This reaffirmed what was already discussed about having benefits in regard to physical and functional well-being and treatment-related toxicities. There was no improvement in emotional well-being on this study, but when it comes down to how we take care of patients with these cancers, we have to…take care of the patient who has the cancer.
A lot of toxicities get lost to focus. Patients sometimes focus more on their CR [complete response] rate and how much they’re going to be cured of this disease. We have to focus in on not just the end of the race but on every mile. When we talk about responses with patients, that would take some time, but we have to take care of these patients as they come and present with each of adverse effects. The benefits of these therapies sometimes last with the durability of the treatments they can tolerate. The toxicities are of significant importance, and these quality measures are quite important. In our clinic, we don’t use measures. We have our patients meet every other visit with psychologists and psychiatrists. We have caseworkers for these patients as well because we have to be able to take care of our patients in their entirety.
A lot of times the visits go too fast, and the goals are redirected in the wrong direction and are more about results of lab studies and scans. These patient-related outcomes are of significant importance, and though we don’t do the real measures that are presented at the meetings, it still takes into the improvement about how we can take care of our patients. Recognizing that though we don’t do these studies and in person, we have to still have those discussions and use your complement of staff in the cancer centers to be able to still take care of your patient in its entirety.
Robert J. Motzer, MD: Thanks very much. There are a couple of subsets of patients of special interest, and those are patients with brain metastases or bone metastases, both of which are often managed generally with localized management. Brian, is there a role for systemic therapy in patients with brain metastases? Do you feel that 1—say, a TKI [tyrosine kinase inhibitor]–I/O [immuno-oncology] or ipilimumab-nivolumab—is better than another in terms of managing bone metastases? We heard about cabozantinib-nivolumab. What’s your take in terms of systemic therapy for bone metastases? Is there a role for brain metastases for systemic therapy?
Brian I. Rini, MD: I’ll start with brain metastases. I’m a believer that brain metastases require local treatment before systemic therapy. I always image the brain—a contrast CT if not an MRI—and then do local therapy, most often SPRT [stereotactic body radiation therapy], to brain metastases before starting systemic therapy. Kidney cancer, unlike melanoma, does not have good data for systemic treatment of small brain metastases with ipilimumab-nivolumab. I certainly wouldn’t give a VEGF TKI to a patient with untreated brain metastases. My patients get imaging and adequate local treatment of brain metastases.
Then I start them on whatever systemic therapy. I’m not aware of any data that any systemic therapies work better in patients with brain metastases. All the brain metastases that I treat have been previously treated with radiation. You can’t tell that response. Maybe others are aware, but I’m not aware of data.
In terms of bone metastases, I go back and forth about whether I believe cabozantinib is better in bone metastases. It depends on the data set you look at. As Bob mentioned, these are underpowered subsets, and they’re not perfect. There are a lot of caveats. We’re all swayed by the early days of cabozantinib in prostate cancer, when there were some dramatic bone scan changes. Although that drug isn’t approved in prostate cancer, so it’s at least the effect on the bone there is not adequate. I don’t necessarily choose cabozantinib-based regimens for all my patients with bone metastases. I’m not aware of other data with the other TKIs from the subset data or otherwise that would suggest an advantage. Like brain metastases, patients with bone metastases quite obviously can need local control as well, whether it’s for pain or stability in a weight-bearing bone or something. They present unique challenges more from local management than systemic therapy per se.
Transcript edited for clarity.