Overview of Renal Cell Carcinoma (RCC)

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EP: 1.Overview of Renal Cell Carcinoma (RCC)

EP: 2.Classification of Renal Cell Carcinoma

EP: 3.Approaching Treatment for RCC

EP: 4.Goals of Therapy for RCC

EP: 5.Recent Advances in RCC Treatment

EP: 6.Phase 3 CLEAR Trial in mRCC

EP: 7.Emerging Agents for the Treatment of RCC

EP: 8.Treatment Selection for the Management of RCC

EP: 9.Managing Adverse Events in RCC

EP: 10.Role of Combination Therapy in RCC Management

Thomas Hutson, DO, PharmD: This is a very exciting time for the management of kidney cancer. Over the past one to two decades based upon research that started in the 1990s, we have now a better understanding of the pathology, the drivers of why patients develop many types of renal cell cancer. This has allowed us to develop new therapies, which are producing significant benefits, such as prolonging life, and allowing patients, even if they cannot be cured of the cancer, to have a longer survival and a good quality of life. To start, I wanted to review some of the basics. First off, when I use the word kidney cancer, I invariably mean renal cell carcinoma. In fact, when you hear someone mention kidney cancer, that’s usually what they mean. But we must remember that not all cancers of the kidney are indeed renal cell cancer. 90% of them are. There are 10% of cancers that arise in the kidney that have nothing to do with renal cell cancer. They are types of bladder cancer, types of lymphoma, sarcoma and sometimes other cancers can spread to the kidney. But rest assured, if you are communicating about kidney cancer you can use that term with your doctor, and they will understand that you mean renal cell cancer.

The next point is to understand that renal cell carcinoma or kidney cancer is not as rare as once thought. When we looked at non-skin cancer, which is everything other than skin cancer, and we look at the incidence and frequency of kidney cancer in men and women in the United States, it ranks somewhere between the fifth to the seventh most common cancer. In the United States, we estimate that there’s roughly 65,000 patients per year [who receive diagnoses of] kidney cancer. Kidney cancer is also a global health pandemic. It is a problem that countries and patients around the world experience. There is a difference in frequency, however, and there are certain geographies and certain races that seem to have a higher incidence of kidney cancer than others. For instance, North American, European and people of the Anglo-Northern European descent seem to have a higher incidence. Renal cell carcinoma, however, has been described in every country, in every region around the world.

The way that renal cell carcinoma presents in 2021 is different than it used to present. There was a time that many of you, depending on your age, can remember when we did not have CT [computerized tomography] scans. A CT scan machine was not available. This is approximately previous to the 1960s. Thus, prior to 1960, when a patient ended up developing kidney cancer, it was picked up very late. In fact, it was called the internist triad, internist meaning the internal medicine doctor triad because it was a diagnosis that family physicians or internal medicine doctors would make. A patient would come into the office looking pregnant, a very large belly, and on exam they would palpate the large mass. Also, once in a while patients would complain of blood in the urine. Thus, that triad of a large mass, abdominal or flank pain, and blood in the urine has been called the internist triad, and that’s how it was diagnosed. Again, later in stage and more advanced, and therefore, less curable.

Now, with the availability of CT scans and other imaging techniques, patients will often get CT scans and ultrasounds for a variety of other reasons and they will be discovered to have a kidney mass. We call that an incidental kidney mass, and on workup of that mass they are then found to have a kidney cancer. And that cancer tends to be much smaller and many times is producing no symptoms at all. Since the cancer is much smaller, it is occurring then at an earlier stage and can be treated and potentially cured at a higher rate than what it was in the past. Again, take-home point is that it’s common now for kidney cancer to present found on workup of some other reason on a CT scan. If a patient does have symptoms in 2021, it’s generally blood in the urine, and the workup of blood in the urine involves a variety of things that the doctor must evaluate. It’s the commonest things that occur most common. Kidney cancer presenting as blood in the urine wouldn’t be the most common cause of blood in the urine. It would usually be things like kidney stones or a urinary infection. Thus, it’s common for doctors to exclude those first. However, if there is persistent blood in the urine, then ultimately a CT scan is done or sometimes the doctor will do a cystoscopy where they look up into the bladder and they ultimately diagnose the renal mass. In order to call a renal mass kidney cancer, it requires pathology.

Now, our radiologists are very sophisticated in 2021, and so they often times are able to give with a high degree of accuracy a diagnosis to the physician where they’ll state on the report of the CT scan that the mass is highly suspicious for renal cell cancer. But as we know, there’s no 100% in life. Thus, we need to confirm this more definitively and that usually involves a biopsy, and there are a couple ways in which one could ascertain the pathology. A biopsy can be done of the kidney with a needle. The patient is sent to the radiology department and a needle is placed into the kidney tumor for diagnosis or even more commonly, since the radiologist has given the doctor an indication that this is highly likely to be kidney cancer, often times the urologist who is the kidney surgeon will just go forward and do surgery and remove the kidney or remove the mass. And the pathologist is then, after the surgery, able to confirm that this is renal cell cancer. Thus, renal cell cancer can be cured as long as it’s localized to the kidney and has not spread beyond the kidney. The likelihood when someone presents with renal cell cancer that they can be cured is roughly 70%. So roughly 70% of patients present with their diagnosis of kidney cancer localized or locally advanced that would be potentially cured with surgical removal of the mass and/or kidney. An additional 20% to 30% of patients unfortunately present at the time they're diagnosed already having evidence on X-rays and CT scans that the cancer has spread beyond the kidney, and therefore, by definition they have metastatic kidney cancer.

In 2021, metastatic kidney cancer remains a cancer that is incurable despite what you may read that there are rare situations where patients can be rendered free of the cancer for many years. We generally do not utilize the word cure in that setting. So again, two ways patients present, localized or metastatic.

This transcript has been edited for clarity.