Dr Yentz on Treatment Decisions in Favorable-Risk RCC

Sarah Elizabeth Yentz, MD, clinical assistant professor, University of Michigan Health, discusses treatment considerations in patients with favorable-risk renal cell carcinoma (RCC).

Patients classified as having favorable-risk RCC represent approximately 20% of RCC cases and have disease characteristics that are distinct from those of other RCC risk sugroups, Yentz says. Therefore, treatment options for patients with favorable-risk RCC often include approaches that may not be optimal in patients with poor-risk disease who are symptomatic and need immediate treatment, Yentz notes. The initial consideration for patients with favorable-risk RCC is whether treatment is necessary at all, as a subset of patients with very low-volume disease can be safely observed, Yentz explains. For instance, some data support active surveillance as an appropriate approach in patients with low-volume disease exhibiting slow tumor growth, according to Yentz.

Another disease management strategy for favorable-risk patients is oligometastatic treatment, Yentz elaborates. This historically involved surgical intervention, but advances in stereotactic body radiation therapy (SBRT) now enable precise, radiation-based treatment in small, localized metastatic lesions, Yentz says. For example, SBRT can target 1 or 2 lesions in specific sites, such as the lungs, Yentz notes.

Regarding systemic therapies, the National Comprehensive Cancer Network (NCCN) guidelines do not recommend using ipilimumab (Yervoy) plus nivolumab (Opdivo) in favorable-risk patients, as clinical trial data from the phase 3 CheckMate 214 trial (NCT02231749) demonstrated a more pronounced efficacy benefit with the combination vs sunitinib (Sutent) in intermediate- and poor-risk patient subgroups compared with the favorable-risk subgroup, Yentz explains.

Many patients with favorable-risk RCC have favorable disease outcomes regardless of the treatment they receive, Yentz says. Additionally, some patients’ disease biologies may be more driven by VEGF than others’, and are thus more responsive to TKIs, Yentz emphasizes. However, the body of evidence from other clinical trials indicates that some favorable-risk patients exhibit durable responses with ipilimumab plus nivolumab and maintain disease control after stopping treatment, Yentz says. Although the NCCN guidelines do not list this combination as a standard of care for favorable-risk patients because of the design of CheckMate 214, it remains a valuable option to consider for patients with favorable-risk RCC, Yentz concludes.