6th International Kidney Cancer Association Symposium, 6—7 May, 2011, Warsaw

The future of kidney cancer therapies

Dr Ronald Bukowski (Cleveland Clinic and the Kidney Cancer Association, USA)

I think I have a very interesting view of the disease because I’ve really taken care of patients with this disease since 1975 when I became a medical oncologist, and I have a long term view and that is how things have changed in the disease, or how things have not changed in the disease, for patients. And my view is predominantly with patients with advanced disease, not surgically curable disease but advanced disease and what is happening in the disease, what’s different in the disease and what advances have we made. And I have alluded to this in several plaques and that is that it has clearly made major advances in the treatment of this illness in terms of patients with advanced disease. We have a number of new medicines that all affect the disease; that slow the growth of the disease,  I’m talking about kidney cancer now. And it does have patients pay a price though; these individuals who take these medications don’t necessarily have a wonderful quality of life. The medicines themselves do have side effects and that is clear, especially in chronic therapy we are seeing now. What we are developing then are a series of medicines which control the disease, don’t cure it.

What do we need? Well we need to understand the medicines that we are using and how better to treat their side effects; what patients may develop these side effects? Are there biomarkers which help us select people who are going to have fewer side effects or more side effects or what about better drugs, I mean are there better drugs right now? The session we have just had at this meeting focussed on new drugs and new targets and do we have anything on the horizon that looks like it’s going to do what I have suggested and that is eradicate disease? Unfortunately no, I think we are still left with these types of drugs that control disease progression at a cost for patients, and so research is important, clinical trials are important. And I think we may have lost sight of this over the past five years because we assumed we had all these treatments and therefore we had therapy for patients with this disease. I think that’s true, we do, but we need to push the outlook; we need to understand what patients benefit. We need to look at new treatment, we need to look at newer ways of approaching this disease, and we need to compare treatments because we are entering a phase in medicine in the United States, and elsewhere in the world, where this is becoming a real issue for us. I mean here we continue to develop new and expensive treatments with very small benefits or limited gains and the answer is no, clearly that we need to pay attention to all of these topics. And so we are facing an era in kidney cancer of unprecedented informational flow; it is going to be a time for development of new drugs, understanding the disease’s biology, but we also have to keep in mind that this is not an open door policy, that we can’t do this in a random fashion; we need to understand that there clearly are some issues which need to be taken into account in terms of societal issues when we start to develop these drugs.

So I am very, very, high on the developments in kidney cancer; I think they have certainly made a different for patients, no doubt about it. But we shouldn’t lose sight of the fact that we have a great deal of work left to do and I think it is always important to keep the bar high here and not to be satisfied with where you are. So I think this meeting in Warsaw really typifies the kind of things I just talked about in terms of what we’ve done and what we’ve seen, and really a lot of the focus today was on what we need to do in the future.

Some of the sessions at this conference touched on multi-modality treatment?

So that’s important, and I think that many of us in the United States perhaps lose sight of this, that this is not necessarily a common approach worldwide. In the United States the multi-modality approach between urologists, medical oncologists and radiation therapists is commonplace; we do this as normal activity but elsewhere in the world the disease may be treated by one segment of that such as urologists or only medical oncologists. And I think the multi-modality approach is an important thing to recognise; it does pay dividends for patients because we all have different subsets of knowledge, urologists, medical oncologists, radiation therapists, and to bring that knowledge together in a way to benefit a single patient is really the goal of multi-modality therapy. So I think we need to keep this in mind as an approach to the disease, and not just to exclude one speciality or another speciality because they all have something to offer for these patients.

What progress is there in deciding which patients will benefit from which therapy?

We still don’t have the answer. I mean I think we have heard approaches to try to understand which patients have side effects by using either a genetic test or a test on their tumour, and certainly the genetic approach is a very intriguing one. Whether this will pay dividends in renal cancer remains to be seen. I mean I think there clearly are people who are presenting at this meeting and have really focussed a lot of efforts on trying to understand the genetic patterns either within a patient or within a tumour that are going to predict at least outcome and then to use that information to develop a way to understand which patients may benefit most from which therapy. We are a long way off from having that answer at this point in time, but I think we have started to move in that direction.

In all diseases when you have this sudden outpouring of knowledge that has happened in this particular area, you need to have a time in which you start to try to understand this knowledge base and then try to understand the benefit to patients, because we have all these treatments but we still don’t understand which patients they would benefit and how to use them. So we need a period of time here to understand this whole series of developments, and that is usually about a five year time frame; it’s not something that happens overnight. This is a lot of work and it takes a lot of cooperation between multi modality specialists and between groups interested in various countries. And so this is where we are at right now, we are in that segment of understanding the disease but it is a five year plan, I think, and so we have to keep that in mind. So if we are back here in five years I think you will see a different approach to the disease, I think it will be one which will be guided by these issues of what biomarkers or how do we select patients for therapy best, or what patients have the most side effects from a particular drug?

We hope these questions will be answered in addition to new treatments because since we’re not curing the disease it is clear we need to understand the targets. And this last session that we had was trying to understand what new targets or what new treatments are on the horizon over the next five years, and what we heard was there are numerous treatments that are being tested and looked at. None of them are ready yet to clearly demonstrate clinical benefit for patients but they are all moving in that direction so I anticipate that perhaps in five years not only will we have six medicines or treatments available but we may have twice that amount. And I think we heard about four or six of them today so when we re-visit this in five years you will see the difference.