MILAN, Italy—Criteria for withholding aggressive therapies early in the course of renal cell cancer were updated at the 8th European Multidisciplinary Meeting on Urological Cancers by Phillip M. Pierorazio, MD, Assistant Professor of Urology and Oncology at Johns Hopkins University, Baltimore.
“In clinically localized small masses—4 cm or smaller—the first-line option is non-surgical management—active surveillance—for many patients,” Pierorazio said, and he went on to discuss the latest evidence on minimizing the risk of unnecessary treatment emerging from his group's registry of patients with renal tumors (Curr Opin Urol 2016;26(5):405-409).
While there has been much encouraging news about new treatments for advanced and resistant renal cancer, there was need to reassure many patients they do not need to treat early stages of the disease urgently, Pierorazio noted. Most patients could take time to allow teams to gather the clinical data needed to make considered decisions based on risk/benefit assessment.
Many Tumors Not Dangerous
“What we try to impart is that most small renal masses are not dangerous. In fact, upwards of 20-30 percent are benign. The majority of the cancers are low-grade indolent tumors or not dangerous cancers,” Pierorazio explained.
He recognized that some patients particularly wanted to avoid surgery and—for them—an active surveillance management strategy was viewed as a completely safe option—at least in the short term.
According to Pierorazio, there were penalties for proceeding with active therapy. “No kidney surgery is without risk. The kidney is a very vascular organ. It gets a quarter of the body's blood flow per minute. So, temporarily stopping blood flow, removing tumors, [and] reconstructing kidneys subject patients to risks they may not necessarily need.”
During surveillance, however, there were triggers for intervention, Pierorazio noted. “We image every 6 months for 2 years then annually thereafter. Historically, the biggest trigger for intervention has been a growth rate of greater than half a centimeter per year. But that's probably not the right trigger.”
He highlighted, instead, the importance of overall tumor size, pointing out that a marked upswing of risk that a patient will have a serious cancer—from below 1 percent to the order of 2-3 percent—typically began at around a diameter of 4 cm. So, he regarded monitoring tumor size as a key factor in decision-making.
When he was asked about outcomes following active surveillance as compared with more aggressive approaches, Pierorazio said that, in his group's registry study of patients with early renal cancer, only two out of 500 patients died of kidney cancer, both of whom had up-front surgery.
“None of the patients in the active surveillance cohort has developed metastatic disease or died of kidney cancer. Thirty percent of them ‘progressed’—meaning their tumors grew—but only about 15 percent of them crossed over into intervention,” he reported.
Best Candidates for Active Surveillance?
“We know tumors of less than 2 cm are really indolent,” said Pierorazio. “We do not miss a window of opportunity for treatment or cure if we allow them to grow and keep an eye on them, and most of them will not grow or change.”
Although teams have traditionally regarded older patients who have comorbidities as candidates for active surveillance, there was, in fact, another distinct group. “Any patient with a small tumor is certainly eligible for active surveillance,” he said.
“Active surveillance is a safe option for all patients with clinical T1A tumors—4 cm or less,” Pierorazio concluded. “It really should be our first-line management for patients who are older with co-morbidities, but it can be considered first-line management for any patient with a tumor less than 2 cm.”
Peter M. Goodwin is a contributing writer.
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