Active surveillance: A potential role in metastatic RCC?

A new prospective phase II trial suggests that immediate treatment is not necessary for all adults with advanced kidney cancer and that active surveillance may be suitable for some without the disease worsening.

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Since its publication online in The Lancet Oncology (Aug. 3, 2016), the study has given credence to those who believe active surveillance and close monitoring for evidence of disease progression is suitable sometimes rather than starting immediate treatment with highly toxic anticancer drugs.

“This is something that was done, but not formally prospectively studied before,” lead author Brian Rini, MD, of Cleveland Clinic Taussig Cancer Institute, Cleveland, told Urology Times. “Patients and doctors can find some comfort in the fact that they don’t necessarily need to be treated right away. It’s obviously a clinical decision between the doctor and patient and based on the comfort level and disease, and some intangibles that are hard to objectify.”

During the time between Aug. 21, 2008, and June 7, 2013, Dr. Rini and colleagues analyzed 52 patients with treatment-naive, asymptomatic, metastatic renal cell carcinoma from five hospitals in the U.S., Spain, and the United Kingdom.

The patients were put under surveillance and radiographically assessed at baseline every 3 months during the first year, every 4 months for the second year, and every 6 months thereafter. The patients continued on observation until initiation of systemic therapy for metastatic renal cell carcinoma.

On average, the authors observed patients for a little over a year. There was a cohort of patients only observed for one or two scans, said Dr. Rini, as well as a cohort who were observed for many months to over 3-4 years.

Next: Who are the best candidates?

The findings showed a subset of adults with advanced kidney cancer have slow-growing disease that can be safely managed using active surveillance, sparing them debilitating side effects of aggressive treatments for anywhere from a year to several years. The average time elapsed before patients on active surveillance needed to start chemotherapy was almost 15 months, with their overall average survival being 44.5 months.

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“It’s not for everybody and we don’t claim everyone should be doing it, but it is for a reasonable proportion of patients,” Dr. Rini said. “The best candidates are low-volume, slow-growing disease, and though both are subjective terms, you know it when you see it. A patient with 5- to 8-mm lung nodules growing slowly by a couple of mm over several months doesn’t probably need immediate attention.”

While the study size was small, and Dr. Rini would like to see a larger group of patients or a randomized trial, he doubts that will ever happen because no drug company would fund such a study and it would be difficult to accomplish.

Still, he believes the approach will gain some momentum, especially considering the Taussig Cancer Institute sees nearly 250 metastatic kidney cancer patients per year compared to the handful that most community oncologists see.

“I think people might do it a little bit more now because there is this data that provides them some reassurance. I think that’s reasonable to expect,” he said. “Publication always provides weight. I wouldn’t be surprised if more community oncologists, who don’t have the level of experience and see the number of kidney cancer patients we treat, might be a little more comfortable with this approach.”

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