Adjuvant Therapy for Advanced Kidney Cancer: Who, What, When

First, the doctors discuss when to bring up adjuvant therapy. All three doctors agree that having the discussion early with patients is helpful to the patient and other specialties involved if the cancer is expected to be aggressive after reviewing initial imaging. Dr. Bensalah usually waits until the final pathology results arrive in order to determine the specifics of the adjuvant therapy treatment and refer his kidney cancer patients to medical oncology. He does not use nomograms if the patient does not ask for specific rates of recurrence. However, Dr. McKay uses nomograms often.

Next, the doctors discuss different oncological factors that may convince them to start their patients on adjuvant therapy, such as a large tumor size, advanced tumor stage/grade, an IVC thrombus, extrarenal metastases, and nodal involvement. Additionally, patients with multiple comorbidities and elderly patients may benefit from adjuvant therapy. Both Dr. Bagrodia and Dr. McKay agree that genomic sequencing of tumors is not helpful in making the decision to start adjuvant therapy, as there needs to be more research around this topic. Dr. Bensalah then explains the difference between approval and billing of tyrosine kinase inhibitors (TKI) in Europe.

Finally, the doctors discuss different clinical trials centered around the TKI Pembrolizumab (Keytruda). Dr. McKay notes that there have been very few positive trials and that she is reluctant to put her patients under a year of toxicity if there is a chance of overtreatment. Although many people have few mild side effects, severe side effects, such as diabetes, colitis, and fingernail necrosis, can be observed. Finally, the doctors discuss the importance of generating more research on the response of non clear cell renal carcinomas to adjuvant therapy. Currently, all these cancers are classified as one category but have different histology and response to therapies.