Just Diagnosed with Kidney Cancer--Now What? with Charles Ryan, MD and Brian Rini, MD

April 14, 2015
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This podcast is part of a series for patients who have just been diagnosed with a specific genitourinary, or GU cancer. In this series, Dr. Charles Ryan, a medical oncologist and associate professor who specializes in the genitourinary tract at the UCSF Helen Diller Family Comprehensive Cancer Center, speaks with experts on specific GU cancers to shed light on what happens after an initial diagnosis. 

Today’s guest is Dr. Brian Rini, an associate professor of medicine and a staff member in the Department of Solid Tumor Oncology at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Dr. Ryan and Dr. Rini discuss the decisions that doctors make when a patient is diagnosed with kidney cancer, including some of the factors that go into recommending certain treatment options.



ASCO: You're listening to a podcast from Cancer.Net. This cancer information website is produced by the American Society of Clinical Oncology, known as ASCO,  the world's leading professional organization for doctors that care for people with cancer.

This podcast is part of a series for patients who have just been diagnosed with a specific genitourinary, or GU, cancer. In this series, Dr. Charles Ryan, a medical oncologist and associate professor who specializes in the genitourinary tract at the UCSF Helen Diller Family Comprehensive Center speaks with experts on specific GU cancers to shed light on what happens after an initial diagnosis.

Today's guest is Dr. Brian Rini, an Associate Professor of Medicine and a staff member in the Department of Solid Tumor Oncology at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. Dr. Ryan and Dr. Rini discuss the decisions that doctors make when a patient is diagnosed with kidney cancer, including some of the factors that go into recommending certain treatment options. ASCO would like to thank Dr. Ryan and Dr. Rini for discussing this topic.

Dr. Ryan: Okay, welcome to the podcast. This is Chuck Ryan, and I'm from the University of California at San Francisco. And today I'm talking to my colleague and good friend Brian Rini, who is a medical oncologist at the Cleveland Clinic, and specializes in kidney cancer, specifically in the development of new therapies for kidney cancer. And Dr. Rini is really one of the world's top authorities on new therapies for kidney cancer, and probably sees more patients with kidney cancer than just about any other oncologist that I know, or even in the country or in the world. So, Brian, Dr. Rini, welcome to the podcast.

Dr. Rini: Thanks, Chuck. Good to be here

Dr. Ryan: So I'm going to jump right in and have you set the stage for us. Imagine that you are sitting down, and you are about to see a patient who's been diagnosed with kidney cancer. For the sake of this discussion, let's say this patient has just been diagnosed, and they have not had any treatment, and they're coming to you for a discussion on what to do next. What are the things that you think? What's your thought process as an oncologist?

Dr. Rini: Sure. So a typical kidney cancer patient that I see would be a man in his late 50s or early 60s. Maybe had some symptom like blood in the urine or fatigue, or perhaps just had a scan for some totally unrelated reason, and is found to have an eight centimeter tumor or mass in the kidney, and maybe abnormalities in the lung. That would be your bread-and-butter kidney cancer patient. So often they come to me after a diagnosis, but let's just say for the sake of argument that it's this type of patient. So the first thing we do in this circumstance is to think about whether or not we should remove the primary tumor in the kidney, even though, based on the CT scans, we think that the disease has already spread. And as you know, there are some very old studies in kidney cancer that show that patients who had their primary kidney tumors removed live longer than patients who didn't. But these are many [crosstalk].

Dr. Ryan: That's a little different from most cancers. Why would you explain to a patient that that's necessary?

Dr. Rini: Yeah, that's a good question. And I usually say those words exactly. I say, "If lung cancer, the disease spread outside, we don't cut out part of the lung, or all the lung, or colon cancer, et cetera." So it is different, and it sort of speaks to kidney cancer being a very unique biologic disease. So in this case, the way I explained it to patients that there's two reasons to do this. One is that it's diagnostic. Kidney cancer is pretty characteristic on a CT scan. You can tell, I would say with 90-plus percent certainty that a mass in the kidneys is a kidney cancer as opposed to something else. But it's not 100% certain. And of course before we treat the patient with any one of the approved or investigational drugs we have at our disposal, we want to be certain that it's kidney cancer. There are different types of kidney cancer we may talk about, so it's diagnostic. And it's also therapeutic, as I mentioned. For reasons that I think are as yet undefined, patients who have this primary tumor removed can live longer. Now it's not every single patient who walks in the door, but if somebody has a very small primary and extensive metastatic disease, I think, the general clinical sense is that kind of patient would not benefit from what's called a debulking nephrectomy, or removal of the kidney.

Dr. Ryan: And in the case of a patient who has a very small primary tumor in their kidney and has no symptoms, no blood in the urine, do you still consider the nephrectomy in those cases, or what's your counseling then?

Dr. Rini: Yeah, you know, it just depends. But generally the way I do it is if the bulk of the tumor, if we take all of the abnormalities on a scan, now if the vast majority of those abnormalities are in the kidney as opposed to other organs, then it seems to make clinical common sense that taking that out would be beneficial, and probably overly simplistic way of looking at it. But you're removing most of their cancer, and they're probably going to benefit more than if you're only removing 10% of it. It's probably not that simple, but it is a good rule of thumb in who to recommend this operation for.

Dr. Ryan: Okay, great. So we both know that sometimes these operations for kidney cancer are not that straightforward. There are situations where removing the kidney requires cardiac bypass even sometimes, where there's invasion into the large veins that lead up under the liver, even up above the diaphragm. And, again, obviously these cases are individualized, but what's your sense on where to draw the line as to when a patient should actually have a nephrectomy as opposed to for example leaving it and trying a medical therapy? And we're going to talk about medical therapy next.

Dr. Rini: So, the ideal patient is a young healthy patient with a large primary tumor and very small lung nodule, who doesn't have extensive local invasion between a tumor and the inferior vena cava, who doesn't have comorbidity that would make surgery difficult. And on the other end of the spectrum is the elderly patient with other medical problems, who has a small primary and extensive metastatic disease. Unfortunately, most patients fall in the middle somewhere. And it really comes down to the clinical judgment of the medical oncologist. And this is where working with the surgeon makes a big difference. Fortunately, a nephrectomy is generally a straightforward operation. There are certainly exceptions. But in comparison, say, to other diseases that you and I see, like doing a prostatectomy—removing a prostate or removing a bladder, which I think are more major pelvic operations—kidney removal can often be done laparoscopically. So it's a little less invasive and risky of a procedure which also factors into our decision making.

Dr. Ryan: Right. Right. Okay. So, great. Let's imagine that you've seen a patient, and in this case the patient is coming to you, and they've had a nephrectomy, and you have the pathology report in front of you. And of course nowadays, I think, it's a good thing, many of our patients get a hold of their pathology reports. They have access to their medical records. As you look through a pathology report, what are you looking for? And what do you recommend that a patient would look for if they were to look at their own pathology report?

Dr. Rini: So, it's a good question. I always tell patients to get all copies of their reports, gifs of their images, because they'll keep track as well as anybody else. And if they move or transfer to another physician, it's always good to have everything organized. So kidney cancer comes in different flavors. The most common type is called clear cell. It's really what our drugs have been designed for, and most trials are geared toward. There is a subset of maybe 10 or 15% of patients with metastatic disease who have what's collectively called non-clear cell, which includes subtypes such as papillary and chromophobe and other even more rare tumors. And although we don't have specific therapies directed at each of those non-clear cell tumors, it is important because it does dictate, probably most importantly, eligibility for clinical trials, which I know we'll talk about. The other features of the patholgy report are probably less important in patients who have advanced disease. I also see patients who have their kidneys out, and who don't have disease outside the kidney, in which case, features of the path report would influence their risk of recurrence, things such as size of the tumor, grade, extension into vessels, et cetera. Once a patient is metastatic, those features of the primary tumors that I mentioned, I don't think, matter that much.

Dr. Ryan: So, as you mentioned and we both know, the vast majority of kidney tumors are what are called clear cell kidney cancer or renal cell carcinoma. And in the case we've outlined or the situation we've outlined, there might be a patient who has already had the cancer spread outside of the kidney. You've recently been part of a team that looked at the issue of whether to start treatment for that metastatic tumor right away, or whether a patient is going to be observed for a period of time. Could you speak to the decision about when to start medical treatment, and of course, then we'll talk about what the medical treatments actually are and how they work.

Dr. Rini: Sure. So kidney cancer is really—you know, I always explain to patients, a very diverse disease. It's the most diverse solid tumor that's out there. Meaning that some patients walk in the door and have very extensive disease, very fast growing disease. They don't respond well to our treatments. And unfortunately, it can be life-threatening within a matter of a few months. And then we have other patients that have a documented and proven metastatic disease, but who can live for many years, upwards of over a decade, either with therapy or sometimes without therapy. There's a natural diversity of how fast people's tumors grow. I often hear patients tell me that some other doctor told them that kidney cancer wasn't aggressive, or they heard this or that, or read this or that. And I explain that the reason there are so many diverse opinions is, because the disease itself is quite diverse.

So something that's been done in clinical practice for decades is, say, the patient that we described, say, they undergo the kidney removing surgery, the nephrectomy. They come back to see you, you do more CT scans. And they just have these small little lung nodules that are maybe five or six millimeters, a quarter of an inch, and they're not really doing anything. And we'll often not treat those patients. And that has been done again over the decades of the course of clinical practice. Probably mostly because, more recently, there really weren't any good therapies for kidney cancer. And I think it was recognized that kidney cancer can be slow growing. We studied that prospectively in a very select group of patients and found that on average we could watch people for well over a year before we as physicians and they as a patient felt that they needed to start therapy. The way I explain it to patients is that we now have lots of therapy [inaudible]. In general, when we talk about exceptions, those therapies are not considered curative. And they clearly have side effects, some life altering for patients. And so I don't think that we're harming patients by waiting to start that non-curative, potentially toxic therapy. And interestingly what we found during the course of this prospective study, this experience described patients loved not [inaudible] thought there would be a lot of anxiety over not getting treated, but at least in our relatively limited experience patients were happy that they received treatment, and were certainly comfortable with the sort of wait-and-see-approach, realizing that there would be treatment down the road.

Dr. Ryan: So are there a lot of tests that can be done? Or are there genomics tests or genetics tests that should be done on the tumor that would tell you that a patient should get treatment sooner rather than later? And if those tests don't exist, are they being researched?

Dr. Rini: Those tests don't exist yet. We're now, as you well know, entering the era of genomics where the ability to look at the DNA of tumors has become easier, simply because it's become cheaper if not [inaudible]. There's no test in clinical use for kidney cancer, testing blood or tissue where I can look at it, and say to a patient with confidence, "I know that your tumor is slow growing based on this genetic test." Right now we use what I would call our clinical common sense. How much disease is there? How fast is it growing? We often have a scan or two, the day before surgery and after surgery to give us some idea of the tumor’s growth. Where is the disease? Is the patient symptomatic? How healthy are they? Just all those things you would put in to the unwritten equation of when to start treatment.

Dr. Ryan: Very good. I want to just back track one moment. We jumped right in to talking about a patient who has metastatic kidney cancer. And that's an important conversation and we'll get back to it. But not everybody of course fortunately has metastatic kidney cancer. And yet many of them still undergo nephrectomies and may come to you after the surgery. Could you just address briefly the issue of whether or not we should be treating a patient with medical therapy after having a nephrectomy in the absence of metastatic disease?

Dr. Rini: Sure. The short answer is no. That there've been many trials over the years—including one recently, I'll detail in a second—that have looked at either giving therapy or not to patients who have just the tumor in their kidney and have that kidney cut out, who can be 70% or 80% risk of recurrence, for instance if they have involvement with lymph nodes. And people have looked at radiation, chemotherapy, and hormone therapy, and immune therapy in that circumstance, and nothing has ever shown any sort of benefit. There was a trial reported just a few weeks ago at the Genitourinary Cancer Symposium by Naomi Haas' group looking at sunitinib and sorafenib, two of our relatively newer agents, being that they might provide benefit in that setting. And unfortunately that study was pretty flatly negative. There are some other major trials going on with a similar drug. But I think, after the first trial was reported, it dampened our enthusiasm that those other trials would show benefit. So the standard of care for any patient who has their kidney resected that does not have evidence of disease is simply observation.

Dr. Ryan: And by observation, what do you typically do?

Dr. Rini: So we do a CT scan of the chest, abdomen, and pelvis periodically, which means every four to six months, or something like that, depending on their risk for recurrence. Some less often for lower risk patients and probably more often for higher risk patients. There's no role, in my opinion, for a PET scan in kidney cancer. I've never ordered a single one. It's not useful in this setting or the metastatic setting. It's just not terribly sensitive or specific when it comes to detecting kidney cancer.

Dr. Ryan: And what would you tell a patient who's just had a nephrectomy, and they feel well and their scans are negative, about symptoms they should watch for? I mean, a lot of patients are very worried that if they have a new pain or a cough or something like that that it's the cancer coming back. Is there any pattern to how this occurs and any recommendation you have for a patient?

Dr. Rini: I think for most patients that have recurrence, they probably don't know it until I walk in and then tell them after having looked at their scan. I think for most patients with kidney cancer that comes back after, it's previously being localized just to the kidney. It shows up as an abnormality on a scan before they will develop symptoms. The most common site of spread is through the lung by far, followed by lymph node, liver, bone probably. So certainly if somebody, say, wasn't getting scans or is farther out, develop those organ [inaudible], really it's what I would call generic cancer symptoms, weight loss, things like that. Occasionally people will present with organ specific symptoms like pain in a bone, a neurologic symptom from disease in the brain, or things like that. I usually try to reassure people that they're going to get aches and pains and colds and flus like everybody else on the planet. And I would be as nervous as they are, but I'd just to provide reassurance that statistically it's unlikely that this is recurring cancer, that it's probably not, but if things persist then they need to call me. So we can move up their scans and investigate it.

Dr. Ryan: I think it's important to point out, you mentioned the adjuvant study from ECOG, an Eastern Cooperative Oncology Group, that was just presented. And in that study the vast majority of patients, who they followed after having the kidney removed, did not experience a recurrence over the course of the follow-up time of the study. And so for many of the patients who are going to be followed, it's more likely that they will not have a recurrence than they would. I think it was 30% or something like that.

Dr. Rini: Yeah, I think, that's about right. Most patients nowadays who present with a kidney mass are discovered, what we would call incidentally, without symptoms. Because they walk into an emergency room, they end up getting a CT scan. And for most patients they have low risk of recurrence, so the vast majority of patients will be cured with a nephrectomy.

Dr. Ryan: Let's go back to the setting now where we have a patient who maybe you've been following after that nephrectomy. And they have a spot or two on the lungs or somewhere else, and ultimately you decide maybe that year of watching has passed. And you've decided that it's time to start medical therapy. Walk me through what you're thinking about at that time as you make that decision with the patient.

Dr. Rini: The way I've explained it to patients recently is that there's three categories of kidney cancer treatment, three big buckets. One is an old drug called Interleukin-2. It's sort of old immunotherapy, if you will. This drug was approved in 1992. And it was approved mostly because there's a small percentage of patients that have a very dramatic benefit. Its value for a larger group of patients or for the group as a whole can be debated. But about 5 to 7% of patients who get this therapy can be cured of their disease. Now this is a very difficult therapy. It's given at highly specialized centers and in an intensive care unit type setting. It's about the worst anti-cancer therapy in terms of side effects. But again, a small percent get cured. So that's kind of the old immunotherapy. And the patient will still pursue that, a very, very, highly select patient. Most kidney cancer patients aren't medically eligible for that therapy.

The next bucket of the therapy is all the targeted therapy that have been developed over the last decade, usually described to the patients as generally being anti-blood vessel therapy. So, drugs like sunitib or Sutent, or pazopanib or Votrient, are commonly used drugs that are pills that are usually called targeted therapy. The other name is anti-angiogenic therapy. I just simplify it and just say anti-blood vessel therapy. And these are pills that help a greater percentage of patients. Most people have some benefit, meaning some tumor shrinkage, on these therapy. But they're generally not considered curative. And I alluded to it before the diversity of the disease. People can not respond at all to these therapies. And I have some patients who've been on probably close to nine or ten years now, on these therapies. There's a huge range of how people respond to those therapies.

And then the last category is clinical trials, which currently are newer forms of immunotherapy. So I mentioned Interleukin-2, a very old nonspecific therapy. These newer therapies are much more targeted, more sophisticated, but they are, as well, not yet approved for kidney cancer, but are being studied at a feverish pace in this disease, as they are in many diseases. And obviously, as an academic referral center, we're trying to direct as many patients into clinical trials in general and to those therapies in particular, because I believe they are quite promising.

Dr. Ryan: Great. So you said that Interleukin-2 is not for everybody and I totally agree with that. Tell me, is there a typical patient who is getting Interleukin-2 and who you might recommend it for? Or do you not recommend it for anybody?

Dr. Rini: We recommend it quite a bit. So at Cleveland Clinic we don't personally give Interleukin-2. It's just not a program that we've ever put the resources behind developing. But I would say that we, as a group, probably refer a good two or three patients a month. So again, a stereotypical patient would be the 52-year-old very healthy young man who has undergone a nephrectomy and now has some kidney cancer deposits in the lungs, but not a tremendous volume of disease, not aggressive disease or symptomatic. Those tend to be the kind of patients who fit into that 5 to 7%. And I'll have a discussion, and I'll give them the numbers. And some of them say, "Sure. I'll do anything for a cure, even if it's only 1 out of 20 patients." And other people look at me like I'm crazy, that those numbers are terrible, and that it's really toxic therapy. But I usually encourage people to go talk to somebody who actually gives the therapy. Because I think, a general consensus is that if you're going to do that kind of therapy, it should be your first therapy. That's not set in stone, but people who give it, that I know and respect, tend to think that way. So I try to think about that first. And if they do it, great. And if they don't, then they come back to me and we move on to other therapy.

Dr. Ryan: So that's a really critical point and I completely agree and that's our practice as well. We don't put patients on sunitinib or pazopanib or one of those agents. And then if that fails to work, then send them for Interleukin. There's, I guess, some data that suggests that Interleukin could be even more toxic in that second line environment, correct? Is that what you're alluding to?

Dr. Rini: There's some limited data either way actually. It kind of depends on who you ask. People think it's more toxic or not. So, I think, the jury's out on that. But having said that to me it's almost a philosophical decision first. Am I a candidate for and am I comfortable with a highly toxic approach with a small chance of cure, or do I want something else?

Dr. Ryan: Right. The philosophical issue being intent of treatment whether it's to be with curative intent or life prolonging in remission and inducing intent, but maybe with a lower likelihood or even no likelihood of cure, as we see with the other therapies.

Dr. Rini: Yeah, I think that's correct.

Dr. Ryan: So the main category of treatment however right now in the US is a targeted therapy, or tyrosine kinase inhibitor, or TKI, or as you called it, anti-blood vessel therapy. Do you think these are all pretty similar or do you have a go-to drug in this case? How do you individualize treatment?

Dr. Rini: That's a difficult question. The thinking of the field, and I would say of me personally, has evolved over the years as additional trials have come out and more data and more patient experience. I think, you could make a general statement that would be available anti-blood vessel therapy, that they all have a grossly similar effect. I don't think, they're identical. But they all have some effect, they're not curative, but we can put them in a category together. Having said that, there are subtle but important differences in terms of how they're given, pills versus intravenous, dosing of drugs. Side effect profiles can differ. And I think, probably many oncologists probably choose which drug they use based on side effect profile and how it might fit that particular patient. In the US, the majority of patients will get either sunitinib or pazopanib. And I think, they're used roughly equally at present. We tend to be sunitinib users, having been involved in the original trials and just having a high level of comfort with the drug. But honestly I think, either is a perfectly appropriate choice. And I think that's really just up to the treating physician.

Dr. Ryan: So there are some patients who have what's been called high risk disease based on blood factors and lactic dehydrogenase or calcium or hemoglobin. There are studies that have been done with drugs for those high risk patients. Does that have any bearing on your decision whether to go with TKI or an intravenous drug?

Dr. Rini: In patients with poor risk disease there was a large trial of the intravenous mTOR inhibitor called temsirolimus or Torisel, that showed actually an overall survival advantage compared to Interferon. It was very interesting how that drug was developed. I don't want to say almost by accident, but the basis upon which they did that trial was a very small retrospective look at a previous study. It turns out that there was benefit. I think, most in this field think that it's unclear whether that drug has unique effects in poor-risk patients, or whether it just happened to be developed that way. I actually feel the latter. For most patients who have that poor-risk disease, which for the patients out there it's really the most aggressive disease, the mostly symptomatic disease, I still tend to give one of the TKIs like sunitinib. Although again, giving this intravenous drug is reasonable. For and for anybody that drug is given weekly, and we have a lot of people travel a fair distance to see us. So probably just by practical consideration. There's not many people traveling to our building to get weekly therapy, but it's reasonable. Those are the subtleties that the physician needs to sort out. And honestly it comes down to sort of comfort level and prescribing patterns over time.

Dr. Ryan: I think, your main point is that just because it was developed in the poor-risk category of patients, it doesn't mean that has to be the treatment for poor-risk patients. I think that's a point that's important for patients to hear. Moving on then, how do you consult patients in terms of the expectations for those drugs, whether it's sunitinib or pazopanib, in terms of what you're expecting to see and how long the patients are going to be on them?

Dr. Rini: I usually tell people that about 70% of people will have tumors get smaller with these drugs. 70, 75% will have some evidence of drug effect. Maybe about half of them will have a little more dramatic effect that we would call a response. That unfortunately means that a good quarter or more of patients won't have any effect. That average duration of effect, at least on the initial drug, is probably not quite one year. But I also counsel them that, as we touched on in the beginning, that it's very diverse. And that I try to give them hope that it could be a long-term response. I have patients on sunitinib now, as I mentioned, five plus years. We have a whole clinic full of those patients having just treated a lot of patients. So it is possible to have a long-term response. Unfortunately it's the exception not the rule. And unfortunately we don't really know what somebody's side effects are going to be. We don't know what their good effects are going to be. It's very empiric. We try it and see what happens. Which isn't terribly scientific, but it's the way we do things at present.

Dr. Ryan: Now just for a patient who's not yet had the opportunity to talk to their doctor about these drugs, are patients able to continue to work? Are they sick in bed when they're taking these medications? What's the typical sort of lifestyle of a patient taking these medications?

Dr. Rini: Patients who are working should continue to work. I mean I always tell patients that they'll know they're getting therapy. I don't have any good therapies without side effects, but if we're just making them miserable on a daily basis, then we're not doing our job. Although these drugs are not chemotherapy, I don't think, they have that level of side effects. But they can have life-impacting side effects. And that's where experience with the drug and having a great team of nurses and other mid-level type supporters can really help in side effect management. It's really a critical piece in giving these drugs is good communication with the medical team, among the medical team - side effect management, supportive strategies - but that's a critical element.

Dr. Ryan: I completely agree. Many patients are able to continue with basically a normal lifestyle. And as you point out, they'll know they're on some sort of a therapy for sure. But I encourage my patients to try to continue being exactly the same person as they were before. So, really great. What about diet and exercise? Do you have specific recommendations or how do you respond when patients ask you about that?

Dr. Rini: Yeah, it's a common question. And I always respond that I wish, I could give them specific advice about what to do, or what to eat, or what to not eat that I know would affect their cancer. But as you know, those studies are few and far between. And I'm not really aware of any good studies in kidney cancer frankly, that show that. So I usually tell people to use common sense. That a good, healthy diet for the cancer patient is probably pretty similar to a good, healthy diet for you and me. Tell them not to spend their life savings on miracle cures. They're not out there, and there's plenty of people who will take their money. And just to let me know what they're doing. Most people are doing something, whether they tell me or not. So I encourage them to tell me, because there can be drug interactions with over the counter and natural products.

Dr. Ryan: So in terms of supplements and vitamins and that kind of thing, you want to know what your patients are taking, but you may not have a specific recommendation that they take a supplement or a vitamin?

Dr. Rini: Correct.

Dr. Ryan: Great. All right. Well, it's a really good overview of what patients can expect. And as you look to the future as a researcher in this field, and somebody who deals with this disease on a daily basis, what are you hopeful about in the future, and what should patients be looking into or keeping an eye on?

Dr. Rini: I think, it's that third bucket of therapy, that newer immunotherapy, which, as you know, there have been drugs approved in lung cancer and melanoma. And I think, are coming soon in kidney cancer. So there's a frantic wave of development of these drugs by themselves, in combination with each other, in combination with some of our standard therapies, et cetera. The next three to five years of our lives as clinical researchers will be sorting out how best to give these drugs, and how to get the most benefit, or maybe identify patients who benefit most. So those are really high on our radar. They're occupying a lot of our time and resources from a clinical trials perspective. And for the newly diagnosed kidney cancer patient, they should absolutely seek out a center of excellence who does clinical trials. Ask your doctor about it. You know, take your time and get some opinions and see what the options are. There's almost never a rush to treat kidney cancer. I tell the fellows here, "Your time is your friend for most patients." You have a little time to think about it, think about what's best for the patient. Do they need treatment right away? What are the options, are there trials? Maybe there's a trial open in a month that they could wait for. But take your time and snoop around a little bit and really be comfortable that you're pursuing the best treatment plan for you.

Dr. Ryan: So the new immunotherapies are different from Interleukin. The key point, I think, is it that all patients will benefit a little, some patients will benefit a lot? What's your vision for how these immunotherapies are going to work in reality in the next few years in kidney cancer?

Dr. Rini: Yes, it's probably pretty early to know, but my sense is that there will be a significant subset of patients who benefit dramatically with long term disease control. Whether that means cure or not, I don't know. But I think, there will be a good—and I am making the number up—but a good 30% or so of patients who can do really well for a long time on these therapies. Then unfortunately some patients who won't benefit at all, et cetera. That's a significant improvement over where we are now. So again, how we integrate those therapies or sequence them or combine them is really the challenge for us trying to develop these drugs.

Dr. Ryan: Great. So, I'm just about to summarize here and close up and want to just have you make a couple other comments. I guess, patients ask you, "Where can I go for more information?" Besides Cancer.Net, which is ASCO's website, is there somewhere else where you might think that they might be able to get information about the disease in general, or support groups, or philanthropy if they wanted to make a gift to help research?

Dr. Rini: The major kidney cancer organization from a patient standpoint in the US is the KCA, the Kidney Cancer Association. And they have a website which I think, is just kidneycancerassociation.org. And they're a good initial resource for information connecting you to local experts. They have patient support meetings around the country. We hold one every year. They sponsor conferences for patients, conferences for doctors. And they're really the major patient support organization. I think, if I have to direct people to one place, it would be to that organization/website.

Dr. Ryan: Great. Well, I want to thank you for your time. And I think, this has been a really informative session for patients, patients' families, and even doctors to listen to. To sort of think about, how you approach this disease and what you're thinking about. I want to just make a couple of brief summary statements. So kidney cancer is a diverse disease, as Doctor Rini pointed out. It's really important to get the diagnosis right, and understand the pathology report, and make sure that your doctor had a good chance to go through the pathology report. We talked about the importance of the nephrectomy, of the removal of the kidney, and how that's a diagnostic test that helps us to know what disease we're dealing with, and also a therapeutic intervention, in terms of eliminating high burden of the cancer. And sometimes actually eliminating all the cancer. And so a nephrectomy is a key part in the management of this disease.

Dr. Rini pointed out that after a nephrectomy, if there's no sign of disease anywhere else, there's really no reason at this point to do medical therapy. Although there are a number of clinical trials that are asking that question and looking at whether or not taking a medicine after having the kidney removed is beneficial. We talked about the three classes of therapies. Interleukin-2 which, as he pointed out, is a potentially curative treatment, but for a minority of patients. And it has a lot of toxicity, so it's generally something we give to younger patients who are more fit in terms of able to take more therapy. And as Dr. Rini mentioned, this drug Interleukin-2, is actually given in the intensive care unit. Most patients do not get Interleukin-2. And most who do get treated are treated with a blood-vessel targeted therapy. He mentioned a couple of them, and those are the standards of care at this point.

And then he talked about the future and how there's a lot of new hope for immune targeted therapies that are being given in clinical trials. And gradually they're getting approved by the FDA for other cancers. And so perhaps they'll be approved one day for kidney cancer as well. Brian, I want to thank you for your time on behalf of ASCO and the patients listening to this. And do you have any other, final parting comments?

Dr. Rini: I think that's a great summary. Again, to just encourage patients to seek out expertise, to seek out clinical trials. Because there's a lot of new drugs being developed in kidney cancer. And I think, a lot of good opportunities to make some real advancements in this disease.

Dr. Ryan: Great, thank you very much again.

Dr. Rini: Thank you.

ASCO:  Thank you Dr. Ryan and Dr. Rini. A comprehensive guide to kidney cancer can be found at www.cancer.net/kidney. And for more expert interviews and stories from people living with cancer, visit the Cancer.Net blog at www.cancer.net/blog.

Cancer.Net is supported by the Conquer Cancer Foundation which is working to create a world free from the fear of cancer by funding breakthrough research, sharing knowledge with physicians and patients worldwide, and supporting initiatives to ensure that all people have access to high quality cancer care. Thank you for listening to this Cancer.Net podcast.