Treatment Sequencing in Advanced Kidney Cancer: prioritizing efficacy when considering quality of life

By Keynote ContributorDr. Cristina SuárezVice President of SOGUG (Spanish Oncology Genito Urinary Group)

Written by Keynote Contributor, Dr. Cristina Suárez.

It is an exciting yet challenging time to be a treating physician in oncology, particularly in kidney cancer. The last decade of scientific innovation has brought an unprecedented shift in treatment options, and people now live longer than before with kidney cancer. Despite this, kidney cancers are the tenth most common cancer globally, with renal cell carcinoma (RCC) the most common type of kidney cancer, making up about 85% of diagnoses. There is no known cure for people living with advanced RCC, and the 5-year survival rate is around 12%, demonstrating the importance of continuing to find new innovative treatments.

The introduction of next-generation tyrosine kinase inhibitors, immunotherapy-based agents, and, more recently, combination therapies have transformed the clinical outcomes of people living with RCC. However, with innovation comes more choice and increasingly complex therapeutic decision-making – often raising questions around the optimal sequence of treatments, particularly in more advanced cases.

With more options in the form of both monotherapies and combinations, physicians are faced with questions about treatments that maintain efficacy, extend survival, and consider patient preferences.

Treatment selection and sequencing to extend survival

Efficacy endpoints such as overall survival (the length of time from the start of treatment that people are still alive) and progression-free survival (the length of time during and after the treatment that a patient lives with the disease but it does not get worse) will always remain critical measures in cancer care. We must continue to keep this front of mind when discussing treatment plans. However, as more treatment options become available, it can be difficult to differentiate between them to ensure we’re selecting the right ones for our patients at the right time.

To better support our patients, we should remember to frame efficacy data in the context of managing patient care from a holistic perspective – patient comorbidities, concomitant medications, willingness and ability to withstand treatment adverse events, preferences in terms of valued outcomes, route of administration, drug accessibility and costs.

To keep up with innovation, guidelines change at pace. In 2021, for example, the European Society of Medical Oncology (ESMO) Renal Cell Carcinoma Treatment Recommendations were updated in light of growing evidence demonstrating the efficacy of combination therapies, recommending them as a first-line treatment for all people living with clear cell RCC irrespective of their IMDC risk group – an RCC specific measure which determines overall survival in patients treated with systemic therapy.

These factors mean that healthcare teams could have questions around treatment selection, particularly when trying to account for and predict sequencing. As physicians, we want to give our patients the best chance from the start of their treatment. I believe it is crucially important to utilize the most efficacious treatment appropriate for patients during first-line treatment selection.

While cognizant of the importance of second- or third-line treatments, data have shown that only around half of people living with aRCC will progress to second-line therapy, and only 20% will progress to a third-line treatment. These data reinforce the significance of the first-line treatment decision in the patient journey, a point where every opportunity should be taken to give patients the best chance of reaching the next stage of treatment or even achieving a complete response.

Empowering patients to have more informed conversations around extended survival

Compounding these decisions around treatment selection is the increasing need to consider efficacy together with quality of life to deliver optimal management and patient satisfaction in real-life settings, as well as being able to keep patients on efficacious treatments for as long as possible. As healthcare professionals, we should seek to make choices that primarily have the potential to allow people to live longer but with the best possible opportunity to live well with cancer.

Many kidney cancer patients, for example, may not be aware of the full range of treatment options available to them – access to clinical trials included. In addition, patients may not feel as though they can question their treatment choices with their healthcare teams. From a healthcare professional’s perspective, they may not think that their patients are interested in hearing all the options, or they are too time-pressured to have what could be a long and detailed conversation.

We can’t shy away from having more open conversations with our patients about how aspects of their treatment may impact their quality of life. Of course, as a doctor, first and foremost, I want to see my patients live longer. Still, now I’m more conscious about integrating personal perspectives into treatment selection, considering the length of time a patient might remain on treatment and patient preferences on how they wish to manage their condition.

Tracking people’s quality of life has several potential benefits, such as better-reflecting patient wellbeing and enhancing communication between us as physicians and patients. If people feel empowered to have these conversations with their healthcare professionals, this could impact treatment decisions and allow us to move into an era where efficacy is not just about survival but also expands to include improving quality of life.

With the rate of innovation in the field, we are in a more privileged position to assess quality of life as an important consideration with patients.

Looking to the future

Looking ahead, I do not doubt that the kidney cancer treatment landscape will continue to evolve rapidly. Some of the points I’ve made around treatment selection and sequencing to prolong survival and quality of life will remain high on the agenda for all treating physicians. However, what is clear is that integrating these factors into our everyday practice remains important, with the aim of personalizing treatment to improve patient care and satisfaction. This is even more pertinent as we see a trend of people living longer with cancer.

What’s central to this approach is open and transparent communication between healthcare teams and our patients. Living with cancer can place a significant physical and psychological burden on people and their carers. Quality of life is becoming an increasingly important consideration when we have conversations with our patients about their treatment. We need to feel comfortable in encouraging these open conversations. Signposting patients to organizations where they can find resources and support, equipping them to have informed conversations about their treatment, will encourage confidence in discussing what’s important to them.

If we do all of this right, this will allow us to move into a new era of cancer care where patients are fully integrated into the treatment decision process, personalizing treatment sequencing aligned to patient priorities to benefit people living with cancer and their families.

References

• Key Statistics about Kidney Cancer. American Cancer Society. Accessed: March 2022. Available: https://www.cancer.org/cancer/kidney-cancer/about/key-statistics.html.
• Kidney Cancer: Introduction. Cancer.Net. Accessed: March 2022. Available: https://www.cancer.net/cancer-types/kidney-cancer/introduction#:~:text=Renal%20cell%20carcinoma.,filtration%20units%20in%20each%20kidney. 
• Padala et al. Epidemiology of Renal Cell Carcinoma. World Journal of Oncology. 2020; 11(3): 79-87
• Dutcher J. et al. On the Shoulders of Giants: The Evolution of Renal Cell Carcinoma Treatment—Cytokines, Targeted Therapy, and Immunotherapy. Journal of Clinical Oncology (ASCO). Accessed: March 2022. Available: https://ascopubs.org/doi/10.1200/EDBK_280817 
• ESMO. eUpdate – Renal Cell Carcinoma Treatment Recommendations (esmo.org). Accessed January 2022. Available: https://www.esmo.org/guidelines/genitourinary-cancers/renal-cell-carcinoma/eupdate-renal-cell-carcinoma-treatment-recommendations-3 
• Heng DY et al. Third-line therapy in metastatic renal cell carcinoma (mRCC): Results from the International mRCC Database Consortium (IMDC). Journal of Clinical Oncology (ASCO). Accessed March 2022. Available: https://ascopubs.org/doi/abs/10.1200/jco.2015.33.15_suppl.e15578 
• Detmar et al. Health-related quality-of-life assessments and patient-physician communication: a randomized controlled trial. JAMA. 2002; 288(23):3027–34.
• Basch et al. Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment. JAMA. 2017; 318(2):197–8.
• Basch et al. Symptom monitoring with patient-reported outcomes during routine Cancer treatment: a randomized controlled trial. J Clin Oncol. 2016; 34(6):557–65. 
• Age and Cancer. Cancer Research UK. Accessed March 2022. Available https://www.cancerresearchuk.org/about-cancer/causes-of-cancer/age-and-cancer 

About Dr. Cristina Suárez 

Dr. Suárez received her M.D in Medicine and Surgery at the Autonomous University of Barcelona. In 2008, she joined the Oncology Department of Vall d’Hebron University Hospital as a Physician (attending staff), of the Genitourinary, Central Nervous System, Sarcoma, and Tumors of Unknown Origin Program. In 2018 she obtained “Cum Laude” qualification when she completed her studies for a doctorate with the doctoral thesis: “Prognostic value of genetic alterations in the mTOR pathway of patients with metastatic renal cell carcinoma treated with mTOR inhibitors” Dr. Suárez has been a co-investigator and principal investigator in several clinical trials related with genitourinary malignancies from 2008 ongoing. She is also an Author and Co-Author of more than 100 scientific papers, posters, and book chapters national and international, especially focused on the area of genitourinary tumors. She is Vice President of SOGUG (Spanish Oncology Genito Urinary Group), an active member of several oncology societies like ASCO, ESMO, SEOM, SOGUG), a Scientific committee member of the American Society of Clinical Oncology (ASCO), and European Society of Medical Oncology (ESMO). 

Disclaimer: This article has not been subjected to peer review and is presented as the personal views of a qualified expert in the subject in accordance with the general terms and conditions of use of the News-Medical.Net website.