The ideal role for cytoreductive nephrectomy for treating patients with metastatic renal cell carcinoma (RCC) is far from clear. The question was the topic of a popular debate at the 2016 ASCO Annual Meeting this year (Oncology Times 7/10/16 issue) and was also the topic of a new retrospective analysis published online ahead of print in the Journal of Clinical Oncology (doi: 10.1200/JCO.2016.66.7931).
The advent of newer targeted therapies has led to a reduction in its use—which has led to a reduction in randomized clinical trials to evaluate the use of it along with newer targeted therapies, Toni K. Choueiri, MD, Clinical Director of the Lank Center for Genitourinary Oncology and Director of the Kidney Cancer Center at Dana-Farber Cancer Institute, and his co-authors explain in the paper.
“But, current guidelines do support cytoreductive nephrectomy in the right clinical context,” Choueiri noted.
Choueiri and his colleagues looked at data from 15,390 patients from the National Cancer Database who had RCC and had been treated with targeted therapies. They found 5,374 patients had the procedure—35 percent of the patients with metastatic RCC in the database.
Patients were more likely to have had the procedure if they were younger, privately insured, treated at an academic center, and had lower tumor stage and nodal stage (cNO). And median overall survival for patients who had the procedure compared with those who had not had the procedure was 17.1 months versus 7.7 months.
Given the 10-month overall survival advantage associated with cytoreductive nephrectomy (which agree with previous studies that have found a similar overall survival advantage), the low rate of the patients undergoing the procedure that was observed in this study is concerning, this paper concluded.
Here's what else Choueiri told Oncoogy Times about the research—and about future research to address the question.
1 Why would you say this study was an important one to conduct?
“Cytoreductive nephrectomy has proven a standard in the era of immunotherapy, and retrospective studies in the targeted therapy era showed that it is still relevant.
“We used a large national database to examine this question and determine factors behind cytoreductive nephrectomy and whether cytoreductive nephrectomy remains associated with survival.”
2 Were you surprised by the findings?
“While not very surprising, it is intriguing to still see that only three out of 10 patients get [cytoreductive nephrectomy]. We expected six or seven out of 10. We discuss in the paper the many factors that could have influenced receipt of cytoreductive nephrectomy, but it is certainly lower than what we expected.
“I think patients presenting with metastatic RCC (20-30% of all RCC patients) would still benefit from a multidisciplinary approach where they meet the medical oncologist and the urologist regarding a plan of action.
“Cytoreductive nephrectomy should be considered in patients with good performance status and limited disease burden.”
3 How do you and your colleagues plan to continue to answer this question about the role of cytoreductive nephrectomy in treating patients with metastatic RCC?
“We will attempt to investigate in the future if cytoreductive nephrectomy will continue to be of benefit in patients who get novel drugs, including immunotherapy. Also, we are awaiting the results of the randomized trials [to answer these questions], notably the CARMINA trial.”
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