Kidney Cancer FAQs Answered on Treatments, Care Teams and More

A cancer journey brings with it plenty of questions for patients, caregivers and survivors. Dr. Thomas Hutson, chief of the Hematology-Oncology Division in the Department of Internal Medicine at the Texas Tech University Health Sciences Center School of Medicine and a member of the CURE®advisory board, recently sat down to answer frequently asked questions regarding kidney cancer submitted by readers and attendees of the CURE® Educated Patient® Kidney Cancer Summit.

How do stage and grade work in kidney cancer?

Hutson: Stage and grade are important features that the doctor is going to utilize to help try to prognosticate what the outcome is going to be on the big things that matter to patients, which are their curability and their survival as well as what the chances are for it to recur, so recurrence rates, and since we now have decades of research, it's also going to help us predict what type of therapies are going to be best to utilize for the patient.

What does the immune therapy adjuvant approach mean for patients with autoimmune disease who are on immune-suppressive medications?

Well, the immune therapy is generally going to be contraindicated in patients that require significant immunosuppression because of active autoimmune disease. And when these drugs first were approved about seven years ago, there was a feeling that there was an absolute contraindication. Now it's much more gray, and it really depends on the controllability of the underlying autoimmune disease, as to whether or not it would be reasonable to attempt one of the new immune therapies. Heaven forbid that we attempt an immune therapy that then makes the underlying chronic autoimmune disease untreatable or flare.

So, it really depends. There are still a couple of absolute contraindications to using immune therapy in the setting of autoimmune disease. One would be if the patient is requiring high levels of immunosuppression for the underlying autoimmune disease, such that that underlying disease is a chronic, severe disease, we wouldn't want to interfere with that. And the second is in the setting of transplantation. So generally, it is felt that if someone is on immunosuppressants because they have a transplanted organ, they would be [at] a risk, a significant risk, of potentially causing the organ that's been transplanted to fail or to reject if we try to manipulate the immune system with immunotherapy.

How can patients best evaluate the expertise of their care provider to make sure they're receiving the best care possible?

That's always the challenge. I think the internet is your friend. There's a caveat here: among experts, we will not always choose the same therapies. The practice of medicine is an art, it's a practice and that's developed both on understanding the published scientific literature, but then also equally involves the history and experience of the physician, and they go hand in hand.

For me, I want patients to receive expert care from someone that I feel knows the literature, and then if they choose something different than me, OK, that's that doctor's opinion, and that's OK. I feel that that doctor knows the literature, I recognize them as being an expert in the field. We just disagree on that, and that happens.

What I don't like, and what the patient needs to be concerned [about] is, if the doctor is even aware of the literature. And how do you figure that out? Well, you can go online and you can search and see if the doctor you're seeing has any expertise as represented by being an author of publications in the field. If you type your doctor's name in, and it's coming up that they are published in kidney cancer, and they seem to be recognized in the world of kidney cancer, as being one of the researchers, well, you're probably with a pretty good doctor. If you're with a physician who you can't find anything on whether they have any knowledge about kidney cancer, then you have to start asking that physician a little bit more questions, like, “How many patients have you treated with this cancer? What has your experience been?” And you can use that. If they're honestly responding with “You know, I don't see many,” well, then maybe you want to get a second opinion.

You can also go to the Kidney Cancer Association and ask them. They keep a list of physicians who are recognized as physicians with special interests in kidney cancer, and there's a variety of other patient support groups, such as KCCure and others.

Can you explain the multidisciplinary approach and why it's so important in kidney cancer care?

We recognize that it's not one discipline in medicine that's going to provide a cure for patients. And in the earliest stages of the cancer, surgery is a potentially curative option by itself, but we've recognized there's no 100% cure with any cancer that we do. The smallest tumors have a chance of coming back. As you get into larger tumors, generally, stage 2, 3 and 4, we recognize that not only is there a chance of cure, but there is an increasing chance that cancer can come back, and there is a role for additional therapy, and that additional therapy is provided not by the surgeon, and it's provided by another type of doctor, and that's a medical oncologist. And so right there, now enters two different types of doctors, making it multidisciplinary.

If you start thinking of doctors who specialize in symptom management, we call them palliative care doctors that would be part of your team. You can see how you can get a group of doctors who are all on the same team that are providing the patient needed treatments to help get them the best outcome. In cancer, it's becoming more and more a joint effort, especially in patients who have more risky cancer.

Is there any difference in efficacy with Keytruda (pembrolizumab) on three-week intervals versus six-week intervals?

No. In fact, based on the available data that exists, based upon the pharmacokinetic understanding of what happens to the drug in the body, I don't know of anyone who's not comfortable with the concept that three weeks is equivalent to six weeks, enough so you know that clearly the regulatory authorities, which are tasked with making sure therapy are both safe and efficacious, i.e. the FDA, feel very comfortable, and they've allowed that label to exist. If there was any issue there that there was a feeling that it would be less, the FDA would not allow that label, and they would mandate a study comparing the two different administration ways, but most people feel there's really no difference.

I personally use intervals of every three weeks most frequently, and the reason I do that is because I want to make sure that I'm getting the patient in the clinic and monitoring them for side effects. And the only patients that I move over to a longer duration, like every six weeks, would be those patients who have demonstrated their comfort with controlling side effects, that they really are able to monitor themselves, and there's a lot of trust there that they're not going to get into trouble by not getting into the clinic because some of the side effects can kind of come up on a patient. We want to ask questions about side effects that may be brewing that the patient may not be as concerned about yet because it hasn't truly impacted their quality of life, and we want to identify those early on, and the way to do that is more frequent visits than less frequent visits. But there are always situations — so, if you're a patient where you're traveling a great distance to come in, that is a conversation to have with your doctor, and as long as there's a comfort there and there's education involved, then having a six week [regimen] may be reasonable.

This transcript has been edited for clarity and conciseness.

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