Sandy Liu, MD: Being in a specialized comprehensive cancer center to treat kidney cancer is really important, because we really need a multidisciplinary team to treat kidney cancer. For every patient who walks through my clinic, I make sure that there’s a surgeon on board if they’ve not had their kidney removed. I also make sure that they see a medical oncologist to see if they need any advanced systemic treatments. If they have a lot of pain, especially in the bones, I tend to refer them to my radiation oncologist to consider palliative radiation to help with pain control. I think a multimodality treatment approach to kidney cancer is extremely essential, and an academic center like UCLA provides that service, as do many academic centers around the country.
All patients, if they have the opportunity, should be referred to a multidisciplinary center. However, community centers offer just as good care and bring all the different specialists together. Even though they are not specifically located in one area, they do have access to different specialists. It’s just a matter of timing and convenience for the patient. That’s why I think being in a community center is fine as long as the surgeon is qualified, performs a lot of nephrectomies and has a lot of experience doing that.
The other thing I like to discuss in a multidisciplinary setting is presenting complex cases in tumor board. We do have tumor board once every other week where the pathologist, the radiologist, the radiation oncologist, the urologist and myself come together to discuss complex cases and to come up with a treatment plan that is otherwise very difficult.
For stage 4 renal cell carcinoma, I look at the patient first of all, to determine what kind of advanced systemic treatment they have. I like to talk to them and understand where they’re coming from. I also have to know their other comorbid conditions: if they have high blood pressure or diabetes; if they have any autoimmune disease, because that really comes into play now; if they have a history of clots, because therapies can affect a lot of their pre-existing conditions. The oral TKI (tyrosine kinase inhibitor) medications we give can especially exacerbate hypertension and cause clotting, as well as bleeding and wound healing. If you have a coexisting autoimmune disease, the immunotherapies can worsen that, so we always keep the patient’s pre-existing conditions in mind.
When I assess a patient in clinic, I always talk to them. We go through their entire medical history. We go through the medication list to see what medication they’re on. I go through their family history and their surgical history to make sure that there are no contraindications to the specific type of treatment I’m giving them and to look at their overall health status, functional status and how they are able to perform their activities of daily living. Those questions are very important for me when assessing if patients are able to tolerate treatment and what kind of treatment I may give them if they have support at home. That’s also very important, too.
Right now, as they are able to look on a computer and use Google, patients are very involved. They’re very knowledgeable. They understand what therapies are out there—maybe not the nuances and the specific details, but they understand the general classes of medications and, generally, the side effects. Some of my patients are very savvy and very involved. They’re very knowledgeable when they come in. They bring a list of questions, as well as what they’ve researched. We go through them, and I think that it’s very important to be an advocate of your own care and know as much as possible before coming in.