CARMENA trial is not final word on cytoreductive nephrectomy

A phase III study published in August 2018 is not the last word on the role of cytoreductive nephrectomy in the current era of targeted therapy, according to Robert C. Flanigan, MD.

While cytoreductive therapy has been the standard of care in metastatic renal cell carcinoma (RCC) for 2 decades, the introduction of targeted therapies has raised questions about this standard, said Dr. Flanigan, of Loyola University Medical Center, Maywood, IL. Authors of the Clinical Trial to Assess the Importance of Nephrectomy (CARMENA) examined the role of nephrectomy in patients with metastatic RCC who were receiving sunitinib malate (Sutent), a potent targeted therapy, and found that sunitinib alone was not inferior to nephrectomy followed by sunitinib (N Engl J Med 2018; 379:417-27).

Dr. Flanigan discussed the current role of cytoreductive nephrectomy at the Society of Urologic Oncology annual meeting in Phoenix. In a video interview with Urology Times, he points out the shortcomings of the CARMENA trial, patient selection for cytoreduction, and the future of cytoreductive nephrectomy in the age of PD-1 inhibitors.

“There have been many, many retrospective database studies looking at cytoreductive nephrectomy in the interim, almost all of which have shown an advantage to cytoreductive nephrectomy, even in the targeted therapy era,” Dr. Flanigan said. “I think the unfortunate thing if you look at it from the point of view of patient outcomes is, I don’t think the CARMENA trial really changes our practice.

“All of us would prefer to have better results for our patients with a minimum amount of interference with their lives. There will be a time when that changes, but I don’t think this CARMENA trial is going to change it at this stage of the game.”