Healthcare professionals reflect on recent evolutions in the renal cell carcinoma treatment landscape.
Hans Hammers, MD, PhD: I want to say where things might be going. For kidney cancer, there is not too much, but because you were in dire straights, there was no time we could lose and we had to start in therapy right away, there is an academic institution. We do clinical trials and something we like to offer patients is clinical trials at every stage, like previously untreated patients, patients who progress on prior therapy, and stages like that. The horizon might even be some of the expansion, for example, triple therapies may be coming where we combine not just 2 drugs, but maybe even 3 drugs. One class of drug that is coming is a third leg, where we have the blood vessel inhibitors pills, Lenvima, that you are taking. We have the immune check inhibitors such as nibulamab and pembrolizumab, and then the third leg for kidney cancer is going to be the HIF-2 inhibitors, these are very unique drugs that target a transcription factor called, hypoxia-indicible factor 2 (HIF-2), which is the protein that goes up and reprograms the cell, if the cancer lost the sensor for oxygen, or doesn't see any oxygen. It's really at the heart of how kidney cancer thinks and prepares itself to be more aggressive and survive adverse circumstances and drives some of the thinking of what these cells are going through and why they're becoming aggressive. It is a unique pill in fact that has few [adverse] effects and in fact, patients must think about what the [adverse] effects are and they can lead to lower red blood cell counts, but it's certainly a treatment that's coming for kidney cancer patients. There are many of clinical studies and others exciting things that are going on, so we're grateful for the community of scientists and the pharmaceutical industry as well as others who work to continue to improve agents that we can use for the care of our patients. Not everybody can just pick up their grandma, jump in a car, and save a life by driving to a large academic place. Often, patients have to engage and that's where the majority of patients are being treated in the community, which has partners in our goal to deliver excellent care. What kind of advice do you have when we treat patients out in the community, or work with community physicians to deliver some of the care, especially for patients who don't live close to the cancer center? What is some of your advice? Maybe you want to start, Laura?
Laura Sanza, PhD, MPAS, PA-C: When people come for an opinion from afar and they are so impressed that they want to get care here, we're always open to accommodate as best as we can and we do use telehealth visits, which can be helpful so that they don’t have to drive in all of the time, but sometimes, we point out that a different approach, which may be easier for them, is to consider establishing with a local oncologist and utilize our team as a consultant. We can review at each juncture, the response to a certain treatment, or the need to consider a different treatment and then, they can get the treatment because these recommendations would all be standard care options, so it's just a matter of choosing based on risk assessment. Do they have a high-risk disease, or low-risk disease, and support the decision of a certain treatment that they can get locally. The reason this might be advantageous in certain situations, especially those that are an airplane ride away, or five hours away for example, is when they develop toxicity and there's just so much you can do over a telehealth, if there are concerning symptoms. It would be best to be seen and evaluated by listening to lungs, feeling on the belly, checking labs for electrolytes, checking blood pressure, and seeing what their oxygen demand is. We can't do these things over telehealth, and treating people far can lead to compromise, if they are not established with an oncologist, then they're stuck with going to the local ER where those doctors may not be familiar with the [adverse] effect profiles from the immune therapy and immune mediated adverse events that could be life threatening if not addressed immediately or appropriately, or even the [adverse] effects from the targeting drugs. So, we are giving them the reassurance that they could have more than one oncology group working with them. We work with patients who also go to MD Anderson all of the time, so we put that out there as an option to consider.
Hans Hammers, MD, PhD: Linie, you are someone who has to do the stretch to make sure things go safely in the long run? What is your perspective?
Linie Chi, NP: For most of the patients you see who live long distance, it's about getting imaging and lab work. It's a lot of communication, so there's a lot of phone calls, and most of the phone calls are from people who live far away. Imaging tells you that it will take a week to get here, and it's 2 or 3 weeks, and we have to keep postponing a visit and I have to keep apologizing for it. Sometimes, it gets here, and sometimes it never gets here. I could send out lab work and for some reason, the orders don't go through to patients in lab; there's no lab orders. Like Laura said, a MyChart comes in, I call to triage, the patient is a far distance away, and there's no way they can get here. So, we have no option but to send them to the emergency room. You see them over telehealth visits and there's some things, like Laura said, it's best seen in person, but they can't afford to pay a plane ticket that often and they can't get someone to come with them that often for those of them that are so weak. They pay for hotels and all of that and that's where, like Laura said, social work comes in, so that you're able to help them with accommodations and transportation reimbursement. Sometimes, we keep saying over the MyChart that the worst that can happen is you ask and the answer is no, but usually, social workers find so many ways for you to get here and try for you to find a local hospital for imaging. We do try but, like you said, at some point, the local oncologist just happens to work better in the end.
Transcript edited for clarity.