Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the role of cytoreductive nephrectomy in the treatment of patients with renal cell carcinoma (RCC).

Traditionally, cytoreductive nephrectomy was reasonably well-used in patients with RCC. This was based on findings from 2 studies that compared surgery versus interferon versus interferon alone, showing superior outcomes with surgery. These studies were done before tyrosine kinase inhibitors (TKIs) were being used in RCC. Drake says that in the modern era, the superiority of cytoreductive nephrectomy to TKIs came into question, which led to studies such as CARMENA.

Findings from the CARMENA trial in metastatic RCC showed that sunitinib (Sutent) as a single agent was noninferior for median overall survival (OS) compared with sunitinib plus cytoreductive nephrectomy. Median OS for patients who received sunitinib alone was 18.4 months, compared with 13.9 months for the surgery arm (HR, 0.89; 95% CI, 0.71-1.10). Additionally, sunitinib produced similar median OS results for patients with intermediate (23.4 vs 19.0 months; HR, 0.92; 95% CI, 0.68-1.24) and poor prognosis (13.3 vs 10.2 months; HR, 0.85; 95% CI, 0.62-1.17).

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Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the role of cytoreductive nephrectomy in the treatment of patients with renal cell carcinoma. 

Dr. Drake on the Role of Cytoreductive Nephrectomy in RCC

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the results of the CARMENA study in patients with metastatic renal cell carcinoma (mRCC).

Results from the phase III CARMENA trial demonstrated the noninferiority of sunitinib (Sutent) alone compared with cytoreductive nephrectomy followed by sunitinib in patients with intermediate- and high-risk disease. Drake says that these results? were surprising, and these approaches were statistically equivalent in terms of overall survival.

Drake believes that the findings from this trial will generally reduce the use of cytoreductive nephrectomy. Nevertheless, the question of patient selection remains. There are some people in the field who believe that they can select patients who will benefit from cytoreductive nephrectomy, Drake says. Overall, cytoreductive nephrectomy is not going anywhere, but global use will go down, Drake concludes.

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the results of the CARMENA study in patients with metastatic renal cell carcinoma.
 

Dr. Drake Discusses the Results of the CARMENA Study in RCC

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the CARMENA trial in metastatic renal cell carcinoma (mRCC).

The phase III noninferiority trial CARMENA compared cytoreductive nephrectomy followed by sunitinib (Sutent) versus sunitinib alone in patients with intermediate- and high-risk mRCC. Cytoreductive nephrectomy is the current standard of care for this population. Drake says that up until this trial, removing the primary lesion from the kidney has not been proven to increase length or quality of life. Most of the retrospective studies that have been done are subject to bias, he adds, as surgeons are able to pick which patient they believe will respond best.

Results showed that patients who had their primary kidney lesion taken out did not necessarily live longer, which Drake says was surprising. The 2 approaches were statistically equivalent in terms of overall survival (OS), proving sunitinib noninferior. The median OS was 18.4 months for sunitinib compared with 13.9 months for standard of care (HR, 0.89; 95% CI, 0.71-1.10). Additionally, the median progression-free survival was 7.2 months (95% CI, 6.2-8.5) with sunitinib alone versus 8.3 months (95% CI, 6.2-9.9) with surgery plus sunitinib.

Dr. Drake Discusses the CARMENA Trial in Metastatic RCC

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses immunotherapy agents in bladder cancer.

Currently, there are 4 immunotherapy agents that have data in bladder cancer: 2 PD-L1 antibodies—atezolizumab (Tecentriq) and durvalumab&mdash;and 2 PD-1 antibodies, which are nivolumab (Opdivo) and pembrolizumab (Keytruda).

  Drake says that these 4 drugs look very similar in terms of response rates and adverse events. Some suggest that anti—PD-L1 might be better tolerated, Drake adds, but those opinions are based on cross-trial comparisons.

Dr. Drake Discusses Immunotherapy Agents in Bladder Cancer

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the side effects associated with immunotherapy in genitourinary cancers.

Although the rate of adverse events (AE) is lower in immunotherapy than in chemotherapy, the side effect profile can still be severe. AEs such as colitis and pneumonitis need to be watched carefully, says Drake, as they can potentially be fatal if left untreated.

Drake says that physicians need to be aware of, and manage, these autoimmune AEs and inform their patients that if they are feeling symptomatic to report it, as it may be more serious than the flu. Steroids are a viable and effective option to treat these AEs, he adds, and will not hinder tumor shrinkage.

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the side effects associated with immunotherapy in genitourinary cancers.
 

Dr. Drake on Immunotherapy Side Effects in Genitourinary Cancers

Charles G. Drake, MD, PhD, director of Genitourinary Oncology, NewYork-Presbyterian/Columbia University Medical Center and co-director of Columbia’s Cancer Immunotherapy Programs, discusses the potential of combinations between immunotherapy and conventional therapies in genitourinary cancers.

Combinations of chemotherapy and immunotherapy are showing promise in bladder cancer, where traditional chemotherapy regimens are given upfront with immunotherapy. Drake predicts higher response rates and increased progression-free survival, but questions on overall survival remain.

Another combination that is potentially exciting, says Drake, is pairing hormonal therapy with immunotherapy in prostate cancer. Trials were conducted in patients before surgery, where immunotherapy seemed to be an effective addition to hormonal therapy.

Charles G. Drake, MD, PhD

Articles

Dr. Drake on the Role of Cytoreductive Nephrectomy in RCC

Dr. Drake Discusses the Results of the CARMENA Study in RCC

Dr. Drake Discusses the CARMENA Trial in Metastatic RCC

Dr. Drake Discusses Immunotherapy Agents in Bladder Cancer

Dr. Drake on Immunotherapy Side Effects in Genitourinary Cancers

Dr. Drake on Promise of Immunotherapy Combinations in Genitourinary Cancers