DiaLog: Adjuvant Therapy for Aggressive Kidney Cancer

From OncoLog, September 2006, Vol. 51, No. 9

Adjuvant Therapy for Aggressive Kidney Cancer

Christopher G. Wood, M.D.
Associate Professor of Urology and Cancer Biology

Every postoperative visit, the inevitable question comes up, “What can I do to make sure this doesn’t come back? I want to be as aggressive as possible!” We tell patients that the vast majority of people with renal cell carcinoma are cured surgically, so we’ll watch them closely, but they don’t need further therapy.

It’s true that relapse is rare, but when it happens, the outcome is usually less than satisfactory. The fact that we currently have no effective adjuvant therapy to decrease the risk further is our Achilles’ heel—but researchers are working hard to change that.

Logically, therapies that demonstrate some efficacy in the metastatic setting should have a greater impact at a time of minimal residual disease, but this approach hasn’t, thus far, translated into success in renal cell carcinoma. The mainstays of therapy for metastatic disease have shown no benefit in the adjuvant setting. We have, however, learned some important lessons:

• What side effects are patients willing to tolerate for the possible benefit of an experimental therapy? Toxicity versus risk of recurrence becomes the equation that determines what a patient will endure. With a low risk of recurrence, patients are less likely to try a treatment with even modest toxicity.

• The importance of placebo: New therapies are tested against the standard of care, which in this case means doing nothing. Patients who are motivated enough to participate in a clinical trial are usually keen on getting the drug being tested and see a placebo arm as lesser therapy for their disease.

• It may be that the biology of tumor progression and metastasis is completely different in locally advanced disease and therefore requires different treatment approaches. It may be time to change the way we identify potential agents for use in the adjuvant setting.

• Locally advanced renal cell carcinoma is rare, which is a blessing, but it is also a curse for populating clinical trials. I think it’s important to target our efforts carefully or risk undermining the clinical trial process. There currently are three adjuvant trials ongoing in the world, all with lofty accrual goals. Probably the most significant of these is the ECOG intergroup ASSURE Trial, which compares one year of sunitinib or sorafenib with placebo after curative nephrectomy. The accrual goal is over 1,300 patients and will require the efforts of everyone treating kidney cancer to complete. There are many promising drugs in the pipeline, but they will have to wait in line for these ongoing trials to finish or we risk diluting our efforts.

Effective adjuvant therapy remains elusive right now, but I believe we are closing in. I look forward to the day when I will be able to tell postoperative patients, “Take this, and it will increase the probability that your kidney cancer will not come back.”

For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789.

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