Kidney cancer treatment requires focus, consideration of treatment-associated events

Treatment of advanced kidney cancer has evolved considerably over the last decade, and multiple agents are available, including oral TKIs, mTOR inhibitors, and regimens that include anti-VEGF agents.

Kidney cancer is diagnosed in about 60,000 patients each year, and nearly 13,000 deaths related to this disease occur annually. While more men than women are diagnosed with kidney cancer, older patients are affected more than younger patients.

The disease is one of the more troublesome malignancies, in part because of the fact that about 20% to 30% of the patients will already have malignant spread at the time of diagnosis, according to Michael S. Ewer, MD, MPH, professor, division of internal medicine, University of Texas System Cancer Center, M. D. Anderson Hospital and Tumor Institute, Houston.

“When possible, surgical removal may be curative,” Dr Ewer told Formulary. “The goals of modern treatments for kidney cancer are to prolong survival, and to do so with an acceptably low incidence of severe or debilitating adverse events; modern therapies have been successful, at least to a meaningful degree, in achieving these goals. There is considerable confusion regarding complication of treatment of kidney cancer, and the time is now ripe to alert patients, providers, and third-party reimbursement entities to the potential benefits of modern therapy.”

IMPORTANT TAKE-AWAY MESSAGE

There are 2 important take-away facts that might not be sufficiently understood by clinicians taking care of patients with kidney cancer, according to Dr Ewer.

The first is that much variation exists in the ultimate impact of treatment-associated events.

“While we grade events on a scale of mild to severe, the grading may miss clinically important metrics such as reversibility and long-term burdens of treatment,” he said. “As an example from the cardiac standpoint, moderate heart failure that resolves with treatment of underlying elevated blood pressure, then allowing a patient to continue treatment with a low probability of recurrence, is very different from what can be seen with other treatments that may cause heart failure that appears similar at the time of diagnosis, but that does not resolve and causes more serious later disability. These variations must be understood in order to provide optimal benefit while balancing patient safety to patients being treated for kidney cancer.”

The second important consideration is that events associated with treating patients with kidney cancer often can be managed in a more focused way by consultation beyond the oncologic specialty, he explained. “This has been demonstrated with regard to both dermatologic and cardiologic adverse events,” he said.

According to results of a survey of physician perceptions of kidney treatment management approaches from Sermo, barriers to optimizing treatment included inability to predict patient response.

“These variations include measurements of efficacy as well as the extent and ultimate outcome of adverse events,” Dr Ewer said.

The survey also found that the dissemination of information regarding treating patients with kidney cancer was suboptimal, and that patient adherence to strategies designed to recognize and treat adverse events was not optimal despite considerable efforts designed to educate patients.

Optimizing patient care in the event of kidney cancer should probably start with oncologic evaluation and continue through the periods of treatment and post-treatment surveillance. “Each of these periods require special consideration: the pretreatment period may benefit from the expertise of a cardiologist to optimize blood pressure and improve cardiac reserves so as to reduce the likelihood of these events occurring during treatment; the dermatologist may offer crucial management strategies for the treatment of hand-foot syndrome during treatment; the internist or supportive care physician may play an important role in dealing with post-treatment concerns,” Dr Ewer explained.

A misconception regarding cardiac events is that at any given degree of cardiac dysfunction, the long-term effects will be progressive and potentially severe. Several of the drugs that have entered the anti-cancer therapeutic armamentarium in the last decade have demonstrated reversibility of treatment-related cardiac dysfunction, a distinction from the cardiac damage that follows the use of agents classified as anthracyclines. Heart failure associated with anti-cancer treatment, therefore, represents a more complex group of responses; not all heart failure is the same. New data suggests that not all treatment-associated cardiac dysfunction must result in stopping these agents at the first sign of cardiac involvement, or that any cardiac event associated with cancer treatment carries a uniformly significant burden for the patient.

“Notwithstanding these very different concerns, the ultimate goal remains constant-allowing the patient to achieve maximal benefit from modern treatment strategies while keeping adverse events in check,” Dr Ewer said.