Considerations for Treatment Decision Making for Advanced Renal Cell Carcinoma

Eric Jonasch, MD: Dr Bhatia, what factors do you take into consideration when choosing among the available treatment options? Do you look at patient age, comorbidities, or prognostic features? What other factors do you use when you choose 1 of these regimens?

Sumeet Bhatia, MD: Any patient who walks into our clinic, the first thing we do is try to determine the IMDC [International Metastatic Renal Cell Carcinoma Database Consortium] risk stratification, which takes into account the performance status, time to diagnosis, the hemoglobin, calcium, neutrophil count, and platelet count. We put them into 3 broad categories. Those with 0 risk factors have a wide range of options for them. For those who have more than 1 risk factor, we look at the performance status and try to decide the most appropriate regimen. The presence of hematuria, as well as brain metastases, does play into our decision-making. We also radiographically try to evaluate if by nephrectomy we can get rid of more than 95% of the bulk of the tumor and, based on that, decide what the most appropriate treatment options would be.

Eric Jonasch, MD: Do you use biomarkers for your treatment of patients with renal cell carcinoma? Are you guiding any of your therapy with either molecular or other markers?

Sumeet Bhatia, MD: No. For up-front therapy, we don’t depend on biomarkers. Metastatic kidney cancer seems to have become the first, probably the only, condition in which I don’t wait for next-generation sequencing, which we obtain through Tempus [DNA cancer testing] to guide our therapy. Clearly, if somebody has a history of 1 hemolytic disease, with the new drugs available, it may be different. As a matter of fact, in our practice, usually on first relapse you always have next-generation sequencing available. But I still struggle with how to use it and incorporate it in our clinical practice. The major purpose of having that is to guide patients’ enrollment into clinical trials. But it doesn’t change our standard clinical practice in first- or second-line therapy. How about you, Dr Jonasch?

Eric Jonasch, MD: I agree. We’re probably 5 or 10 years behind breast cancer and lung cancer with regard to that. We’ve identified what I would call secondary mutations. VHL mutations seem to be an obligate finding, or at least VHL dysfunction in clear cell. The SETD2, BAP1, PBRM1 mutations are defining how they influence the behavior of the tumors, but we haven’t assigned specific treatment regimens to those.

Transcript edited for clarity.