Note: The following summary was prepared for the benefit of patient organisations who focus on kidney cancer. While this summary has been medically reviewed, the information contained herein is based upon public data shared at this meeting and is not intended to be exhaustive. Patients should ask their physician about any information that pertains to their care.
The American Society of Clinical Oncology (ASCO) Conference in Chicago June 1-5 2018 brought together oncology professionals, patient advocates, and organisations from around the world. For kidney cancer specifically, the conference included the presentation of results from one large blockbuster surgical trial, and several smaller studies in kidney cancer that may influence practice. Here are four studies that were of particular interest.
1. Treatment with axitinib after IO (Immune Oncology)
Dr. Moshe Ornstein and colleagues presented a 40 patient study (abstract 4517) showing that axitinib given after IO (immune oncology) therapy was associated with a 9.2 month progression free survival, i.e, the time it for the cancer to start growing again, with good tolerability due to a new way to modify dose in response to toxicity. Side effect rates were reasonably low, with no grade 4 (severe) toxicities. This study shows that you can get fairly good results with axitinib after IO therapy. What we don’t know is whether this drug is superior or equivalent to cabozantinib in this setting, and whether axitinib is capable of potentiating (making more powerful) the immune system.
2. Treatment with pembrolizumab as 1st Line Therapy
Dr. David McDermott presented data from Keynote 427 (abstract 4500) a 107 patient study testing whether pembrolizumab given alone to patients who had not received any prior therapy showed effectiveness. Indeed, pembrolizumab in that setting showed that 42 percent of patients had tumour shrinkage of at least 30 percent, and the treatment was well tolerated with a relatively good side effect profile, with fairly low steroid use. On the flip side, approximately 30 percent of patients had their tumours continue to grow while on pembrolizumab, with no benefit. Pembrolizumab, especially given alone, is still investigational as we don’t know how it stands up to currently established standards of care. However, this study shows us that it may be possible in the future to start with one IO drug, and then layer another drug on if no initial benefit is shown. This strategy could decrease toxicity.
3. Cyto-reductive Nephrectomy and sunitinib in Metastatic Kidney Cancer
Dr. Arnaud Mejean presented data on CARMENA (LBA3), a much-awaited study asking the question of whether we should perform surgical removal (cytoreductive nephrectomy) of the primary kidney cancer in patients prior to starting anticancer therapy. This 450 patient study randomly allocated patients to either undergo surgery upfront followed by sunitinib treatment, or sunitinib treatment alone. There was no statistical difference in outcomes between the two treatment arms, and in fact the trend was toward better outcomes in the non-surgically treated patients. This study shows that performing surgical removal of the primary kidney tumor in every patient with newly diagnosed metastatic kidney cancer is not a wise choice for many, and we need to take a more nuanced approach. A practical alternative is to start with a few rounds of treatment and perform this surgery in individuals where disease shrinkage or overall control is being achieved. Bear in mind that in many countries, sunitinib is a drug that is no longer first choice in this patient population, so the findings are a bit out of date.
4. Cyto-reductive Nephrectomy with IO Therapy
Dr. Jianjun Gao showed how we can integrate cytoreductive nephrectomy along with IO therapy in abstract 4520. In this study patients were treated with upfront IO therapy, which was either nivolumab, nivolumab plus bevacizumab, a blood vessel starving or antiangiogenic agent, or nivolumab plus ipilimumab, another IO agent. In the subgroup of patients who had their primary kidney tumors in place, the choice to remove the tumor was made on a case-by case basis by the Urologist and Medical Oncologist treating the patient. Excellent tumour shrinkage was seen, with over 30 percent response rate, which, when including the surgical removal, was even higher. Although this was a relatively small, 105 patient study, the findings support the concept of starting treatment and then deciding later whether consolidative surgery is appropriate in people who are receiving IO therapies.
Thank you to the kidney cancer patients worldwide who took part in the studies presented at ASCO 2018. We are deeply grateful to each patient and their families for this tremendous contribution.
We look forward to more research news to be published at the European Society of Medical Oncology (ESMO) in October 2018. Many clinical trials are currently ongoing and will contribute to improvements in how we diagnose and select appropriate treatments for each individual diagnosed with kidney cancer.
For more information about ongoing clinical trials for kidney cancer around the world, please see: IKCC Clinical Trials Search.