home_cover_v14n3pic_posadas“Exciting development.” Practice-changing.” Unprecedented.” These are the bold terms frequently used to characterize recent developments in the treatment of renal cell carcinoma (RCC).  In the past five years, we have come a long way. Ten years ago, we had a limited repertoire of cytokines which were difficult to use and beneficial to a very limited subset of patients.  Now we have more than 11 effective treatments with 8 therapies that were approved in the past five years.

Most impressively, in the past six months, we have approved three new therapies. That has been the change, according to Thomas E. Hutson, DO, PharmD, Director of the Genitourinary Oncology Program, Charles A. Sammons Cancer Center at Baylor University Medical Center, Houston, whose comments were recently posted in an online interview.

Until recent times, effective agents were approved for their impact on progression free survival (PFS). Both cabozantinib and lenvatinib (in concert wither everolimus) have demonstrated improvement not only in PFS  but also overall survival (OS) in studies with an active control arm. Nivolumab, a potent checkpoint inhibitor, was also shown to be active in kidney cancer.  Interesting, this agent was found to improve OS with a more modest effect on PFS. This is a significant evaluation and advance for the field.  Even with this progress, more new data continues to emerge.

Since much of this was reported out in the last six months, it will take us time to sort through this accumulated data and to determine how we can optimally utilize these agents in our patients. However, it is clear that all three of these therapies have an important role to play in patient management. As the field moves forward, so does the discussion on the integration of these approaches into the existing paradigm.

If you are fortunate to attend all or any of the major international oncology meetings this year and early in 2017, the treatment paradigm for renal cell carcinoma will be comprehensively discussed, analyzed, and debated. The first of these is already upon us: the European Society of Oncology (ESMO) meeting in Copenhagen, Denmark. Additional results from CABOSUN will be reviewed at this conference. Toni Choueiri, MD, the Principal Investigator on this trial has noted, “The positive outcome of CABOSUN is extremely exciting, as it marks the very first time that a therapy has shown a progression-free survival benefit over standard of care first-line treatment sunitinib for patients with previously untreated advanced renal cell carcinoma.” Results from this trial will be reported in the next issue of the Kidney Cancer Journal.

ESMO will also bring the heavily publicized results of S-TRAC which has been announced as a positive adjuvant study using sunitinib for patients who have had complete resection of high-risk tumors.  This was a startling press release in light of negative findings of the ASSURE (E2805) study- a much larger study with a wider range of patients.  Even with positive findings from S-TRAC, our approach to adjuvant therapy will require much discussion.

A second meeting next month, and the only international meeting to focus specifically on RCC, is the 15th International Kidney Cancer Symposium (IKCS), November 4-5 in Miami. The Kidney Cancer Association will make virtual presentations of the scientific sessions available on its website within several weeks of the conference. This year’s agenda will address many of the issues of combinations of therapy discussed by Nicholas J. Vogelzang, MD, in this issue. (See the KCJ Interview, page 98.) Although this conference presents substantial data from pivotal trials, the informal atmosphere during meeting breaks enables attendees to get together with presenters and review posters in a great exchange of information.

The 2017 Genitourinary Cancers Symposium, known to many as GU ASCO, will convene in Orlando, February 16-18. The agenda will include additional new trial data that will have a significant impact on the treatment algorithm for RCC.

All of these developments will impact our approach to RCC. The rapid succession of these reports underscores how quickly clinical decision-making has need to advance. While, this continued evolution is frustrating for those trying to analyze an ever evolving system, the more im-portant and good news is that we have great options for patients and excellent resources and venues with which to evaluate these options.

Edwin M. Posadas, MD, FACP
Guest Editor