Patients treated with targeted therapy for metastatic renal cell carcinoma (mRCC) may derive significant survival benefit from cytoreductive nephrectomy (CN), particularly if their initial prognosis is good, study findings indicate.
However, “[p]atients with limited expected survival or those with four or more IMDC [International Metastatic Renal Cell Carcinoma Database Consortium] prognostic factors may not receive a substantial benefit compared with those expected to survive longer”, report Daniel Heng (University of Calgary, Alberta, Canada) and colleagues.
The findings arose from a retrospective study of 1658 IMDC patients with mRCC. Of these, 982 patients underwent CN and 676 did not. All patients received targeted therapy, most commonly first-line sunitinib (72%).
As reported in European Urology, patients who underwent CN had significantly longer median overall survival (OS) and progression-free survival (PFS) than those who did not, at 20.6 months versus 9.6 months and 7.6 months versus 4.5 months, respectively.
Adjusting for the fact that patients undergoing CN had significantly better IMDC prognostic profiles did not weaken the association between CN and improved survival, with hazard ratios of 0.60 and 0.75 for OS and PFS, respectively.
Nevertheless, the researchers caution that “[c]areful patient selection is critical in determining if a patient will benefit from a CN”.
Indeed, 3-monthly incremental benefit analysis showed that “[t]he longer a patient was estimated to survive, the greater the OS benefit of CN”, they report.
Patients estimated to survive for 6 months or less experienced a small but significant 0.8-month increase in OS if they underwent CN (4.0 vs 3.2 months). By comparison, the survival improvement was a significant 5.2 months for those estimated to survive up to 24 months (12.3 vs 7.1 months).
However, when adjusted for prognostic factors, only those patients expected to live longer than 12 months derived significant survival benefit from CN, with hazard ratios of 0.85 and 0.72 for patients expected to survive less than 18 and 24 months, respectively.
Prognostic risk factors also affected whether or not patients benefitted from CN; those with one to three IMDC risk factors appeared to derive benefit from CN, whereas those with four to six risk factors did not.
Heng and co-authors note that two prospective clinical trials are set to assess the importance of nephrectomy in RCC patients receiving targeted therapy with sunitinib.
“However, these trials are not anticipated to report for some time, so these retrospective data may guide us until then”, they conclude.
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