Stage IV (KC)

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Contents 1 Overview 2 Surgery for Metastatic Renal Cell Cancer 3 An alternative to surgery 4 Systemic Therapy for Metastatic Renal Cell Cancer 5 Proleukin® (interleukin-2) 6 Interferon 7 Targeted Therapy for Metastatic Renal Cell Cancer 7.1 Sutent® (sunitinib) 7.2 Nexavar® (sorafenib) 7.3 Torisel® (temsirolimus) 8 Chemotherapy is any treatment involving the use of drugs to kill cancer cells. 9 Managing Bone Complications with Bisphosphonate Drugs 10 Bisphosphonate drugs 11 Strategies to Improve Treatment 12 Axitinib 13 Combination Therapy 14 Advances in Immunotherapy 15 Vaccines for Renal Cell Cancer 16 Laparoscopic Surgery 17 References 18 Disclaimer 19 E&OE - Errors & Omissions Excepted

Overview

Patients with Stage IV renal cell cancer have cancer that has spread to distant sites in the body, invaded directly into local structures, or has spread to more than one lymph node. Stage IV disease is also known as metastatic cancer.

Renal cell cancers are typically treated with both local and systemic therapy. Local therapy consists of surgery to remove the entire affected kidney and any surrounding cancer. Systemic therapy is directed at destroying cancer cells throughout the body and may include chemotherapy, targeted therapy, or immunotherapy. Renal cell cancers have historically been resistant to treatment with chemotherapy, and only 10–15% of patients experience an anticancer response to currently available single chemotherapy drugs.

Newer targeted therapies offer better outcomes. With the FDA-approval of the targeted therapies Nexavar® (sorafenib), Sutent® (sunitinib), and Torisel® (temsirolimus), surgery followed by immunotherapy, targeted therapy, or a clinical trial evaluating combination adjuvant therapy has become the standard treatment for metastatic renal cell cancer.[1]

The following is a general overview of conventional and investigative treatments for Stage IV renal cell cancer. Cancer treatment may consist of surgery, targeted therapy, or a combination of these treatment techniques. Combining two or more of these treatment techniques has become an important approach for increasing a patient's chance of cure and prolonging survival.

In some cases participation in a clinical trial utilizing new, innovative therapies may provide the most promising treatment. Treatments that may be available through clinical trials are discussed in the section titled Strategies to Improve Treatment.

Circumstances unique to each patient's situation influence which treatment or treatments are utilized. The potential benefits of combination treatment, participation in a clinical trial, or standard treatment must be carefully balanced with the potential risks. The information on this Web site is intended to help educate patients about their treatment options and to facilitate a mutual or shared decision-making process with their treating cancer physician.

• Surgery for Metastatic Renal Cell Cancer

• Systemic Therapy for Metastatic Renal Cell Cancer

• Chemotherapy for Metastatic Renal Cell Cancer

• Targeted Therapy for Metastatic Renal Cell Cancer

• Sutent® (sunitinib)

• Nexavar® (sorafenib)

• Torisel® (temsirolimus)

• Immunotherapy for Metastatic Renal Cell Cancer

• Managing Bone Complications with Bisphosphonate Drugs

• Strategies to Improve Treatment of Metastatic Renal Cell Cancer

Surgery for Metastatic Renal Cell Cancer

The surgery for Stage IV renal cell cancer is called a radical nephrectomy and involves removing the entire affected kidney, the attached adrenal gland, and any adjacent fat and involved lymph nodes or major blood vessels. Results from clinical trials have shown that radical nephrectomy appears to improve survival of patients with metastatic renal cell cancer.[2][3]

For patients with Stage IV disease whose cancer has spread locally, but not to distant sites in the body, radical nephrectomy may be curative. However, because most patients with Stage IV renal cell cancer have distant metastases, surgery is typically followed with additional systemic treatment. Surgery is considered a local therapy because it treats cancer in a specific area but does not treat cancer that has spread to other locations in the body. Systemic (whole-body) treatments, such as targeted therapy and immunotherapy, can treat cancer that has spread throughout the body.

Some patients can experience long-term cancer-free survival after surgical resection of metastatic cancers. Results of a clinical trial indicate that renal cell cancer that has spread to the lungs can be removed with surgery. Among patients treated with surgery for lung metastases but no evidence of cancer elsewhere in the body, including the kidney, nearly 40% survived five years or more. Patients with only a single site of cancer in the lung experienced the best outcomes; nearly 50% survived five years or more compared with 19% of patients who had more than one site of cancer removed.[4]

An alternative to surgery

It is frequently not possible to perform a radical nephrectomy in older or debilitated patients. In these cases a procedure called arterial embolization is sometimes used to provide relief from pain or bleeding. During arterial embolization small pieces of a special gelatin sponge or other material are injected through a catheter to clog the main renal blood vessel. This procedure shrinks the cancer by depriving it of the oxygen-carrying blood that it needs to survive and grow. Arterial embolization may also be used prior to surgery to make the procedure easier.

Systemic Therapy for Metastatic Renal Cell Cancer

Systemic therapy is administered after local treatment with surgery in order to decrease the chance of cancer recurrence. Despite undergoing surgery patients may already have small amounts of cancer that have spread away from the kidney and were not removed during surgery. These cancer cells are referred to as micrometastases, and they are responsible for causing cancer recurrence following treatment with surgery alone. Adjuvant systemic therapy is considered standard treatment for Stage IV kidney cancer and is administered to eliminate any cancer cells that remain after surgery in order to prolong survival, decrease the rate of cancer recurrence and improve quality of life. Examples of systemic therapies that are commonly used in the treatment of kidney cancer include:

• Immunotherapy

• Targeted Therapy

• Chemotherapy

• Immunotherapy for Metastatic Renal Cell Cancer

Immunotherapy works by stimulating the immune system to fight the cancer. The two most frequently used types of immunotherapy are Proleukin® (interleukin-2) and alfa interferon.

Proleukin® (interleukin-2)

Prior to the FDA-approval of new targeted therapies, Proleukin was the standard of care for patients with renal cell cancer. It is typically administered in high doses as an inpatient treatment and has historically been associated with severe side effects. However, the safety of high-dose Proleukinhas significantly improved over the past decade.

Unfortunately, long-term results of clinical trials indicate that only approximately 15% of patients with advanced renal cell carcinoma have an anticancer response when treated with high-dose Proleukin.[5] For this reason the combination of targeted therapy plus Proleukin is being evaluated in clinical trials.

Interferon

Interferon is naturally produced in the body and stimulates the immune system. Interferon alfa is a compound produced in a laboratory that mimics the action of natural interferon and has been shown to stimulate the immune system to recognize and destroy some types of cancer cells.

Treatment of renal cell carcinoma with interferon appears to produce anticancer responses in less than 15% of patients with advanced renal cell cancer. Because side effects can be severe and it has not been shown to improve survival, the use of interferon alone in the treatment of renal cell carcinoma remains controversial.

Targeted Therapy for Metastatic Renal Cell Cancer

A targeted therapy is one that is designed to treat only the cancer cells and minimize damage to normal, healthy cells. The advantages of cancer treatments that “target” cancer cells may include reduced treatment-related side effects and improved outcomes.

Currently, there are three targeted therapies that are FDA-approved for the treatment of advanced renal cell cancer.

Sutent® (sunitinib)

Sutentis an oral multitargeted tyrosine kinase inhibitor that targets proteins responsible for stimulating cancer cell growth. Two Phase II clinical trials have shown that approximately 40% of patients with recurrent renal cell cancer respond to treatment with Sutent, and approximately one-quarter of patients experienced stable disease for three months after treatment.[6]

Additionally, a Phase III trial that compared Sutentto interferon-alfa in the initial treatment of patients with metastatic renal cell cancer has shown that patients treated with Sutentexperienced significantly longer survival without cancer progression than patients treated with interferon-alfa. Also, more than one-third of the patients treated with Sutentexperienced at least a partial reduction in detectable cancer, compared with only 9% of patients treated with interferon-alfa.[7]

Nexavar® (sorafenib)

A Phase III clinical trial compared Nexavar to placebo in more than 900 patients with previously-treated, advanced renal cell cancer. Treatment with Nexavar significantly improved progression-free survival (survival without a worsening of the cancer). Progression-free survival was 5.5 months for those treated with Nexavar, compared with 2.8 months for those who received placebo.[8] A later analysis of these data also suggested that Nexavar significantly improved overall survival.[9] Based on the results of this study, Nexavar was FDA-approved for use in renal cell cancer.

Torisel® (temsirolimus)

The clinical trial that prompted FDA approval of Torisel included 626 patients with metastatic RCC who had a poor prognosis and had not received prior therapy.[10] Patients were treated with either Torisel, interferon alfa, or a combination of Torisel plus interferon alfa (combination group).

Patients treated with Torisel had longer survival by nearly 3.6 months and significantly longer progression-free survival than patients treated with interferon alone. Patients in the combination group did not experience a significant improvement in survival compared with patients treated with interferon alone. Fewer patients suffered from severe side effects in the group treated with Torisel than in the group treated with interferon. Chemotherapy for Metastatic Renal Cell Cancer

Chemotherapy is any treatment involving the use of drugs to kill cancer cells.

Cancer chemotherapy may consist of single drugs or combinations of drugs and can be administered through a vein or delivered orally in the form of a pill. Renal cell cancers have historically been resistant to treatment with chemotherapy; only 10–15% of patients experience an anticancer response to currently available single chemotherapy drugs.

Managing Bone Complications with Bisphosphonate Drugs

Renal cell cancer may spread to the bone. Bone metastases may cause pain, bone loss, an increased risk of fractures, and a life-threatening condition characterized by a high level of calcium in the blood, called hypercalcemia.

Bisphosphonate drugs

Bisphosphonate drugs can effectively prevent loss of bone that occurs from metastatic lesions, reduce the risk of fractures, and decrease pain. Bisphosphonate drugs work by inhibiting bone resorption, or breakdown. Bone is constantly being “remodeled” by two types of cells: osteoclasts, which break down bone; and osteoblasts, which rebuild bone. Although the exact process by which bisphosphonates work is not completely understood, it is thought that bisphosphonates inhibit osteoclasts and induce apoptosis (cell death) in these cells, thereby reducing bone loss. There is also evidence that these drugs bind to bone, thereby blocking osteoclasts from breaking down bone. Cancer cells release various factors that stimulate osteoclast activity, causing increased breakdown of bone. By inhibiting osteoclasts, bisphosphonate drugs effectively reduce the detrimental impact that cancer cells have on bone density.

Bisphosphonate drugs that are FDA-approved for the treatment of cancer-related skeletal complications include Zometa® (zoledronic acid) and Aredia® (pamidronate). Of these two drugs, Zometa® appears to demonstrate the strongest activity. An added benefit of Zometa® is that it is administered in a dose ten-times lower than Aredia®, which considerably reduces the administration time from several hours to 15 minutes, resulting in a more convenient regimen for patients.

Researchers from Pennsylvania have reported that Zometa® improves outcomes and reduces skeletal complications in patients with renal cell cancer and associated bone metastases. The researchers analyzed data from 74 patients with renal cell cancer who were involved in a larger trial that involved patients with other types of cancers. Patients with renal cell cancer may be at a greater risk for developing skeletal complications than patients with other types of solid cancers. The proportion of patients with renal cell cancer at risk for skeletal complications was nearly twofold greater than the proportion of patients in the entire population (44% vs. 74%).

The patients were treated with Zometa® or placebo (inactive substitute) and compared for the development of skeletal complications, which included bone fracture, spinal cord compression, or the need for radiation or surgery for the treatment of bone metastasis.

Patients treated with Zometa® had a 61% reduced risk of developing a skeletal complication compared with those who received a placebo. Also, the patients who received Zometa® had less cancer progression in their bones and lived longer.[11]

Strategies to Improve Treatment

The development of more effective cancer treatments requires that new and innovative therapies be evaluated with cancer patients. Clinical trials are studies that evaluate the effectiveness of new drugs or treatment strategies. Future progress in the treatment of renal cell cancer will result from the continued evaluation of new treatments in clinical trials.

Patients may gain access to better treatments by participating in a clinical trial. Participation in a clinical trial also contributes to the cancer community’s understanding of optimal cancer care and may lead to better standard treatments. Patients who are interested in participating in a clinical trial should discuss the risks and benefits of clinical trials with their physician. Areas of active investigation aimed at improving the treatment of renal cell cancer include the following:

• New Targeted Therapy for Metastatic Renal Cell Cancer

• Combination Therapy

• Advances in Immunotherapy

• Vaccines for Renal Cell Cancer

• Laparoscopic Surgery

• New Targeted Therapy for Metastatic Renal Cell Cancer

Avastin® (bevacizumab): 

A Phase III clinical trial known as the AVOREN study compared the combination of Avastin and interferon to interferon alone in the first-line treatment of advanced renal cell cancer.[12] The addition of Avastin nearly doubled progression-free survival, from 5.4 months to 10.2 months. There was a suggestion that Avastin also improved overall survival, but additional follow-up will be necessary to confirm this result. Because interferon is no longer considered a standard therapy for most patients with renal cell cancer, future studies will likely evaluate Avastin alone or in combination with other targeted therapies. Early-stage clinical trials suggest that the combination of Avastin plus Nexavar may be promising for the treatment of advanced renal cell carcinoma, although side effects are also increased.[13],[14] These finding will need to be confirmed in larger trials.

Axitinib

A Phase II clinical trial evaluated the investigational targeted therapy axitinib among 52 patients with previously treated, metastatic renal cell cancer. Two patients experienced a partial disappearance of detectable cancer and 21 patients experienced a partial reduction in detectable cancer. Adverse effects of treatment included diarrhea, high blood pressure, fatigue, and nausea. The researchers concluded that axitinib shows clinical activity against refractory, metastatic renal cell cancer.[15]

Combination Therapy

Combinations of chemotherapy drugs, called regimens, may produce more anticancer responses and improve the outcomes of patients with advanced renal cell cancer than treatment with any single therapy. Combination therapy can take advantage of potential drug synergies and non overlapping side effects to improve clinical benefit. Clinical trials are ongoing evaluating combinations of Avastin, newer targeted therapies, and immunotherapy in order to determine whether combinations can improve the outcome of patients compared with the use of any single drug.

Advances in Immunotherapy

Inhaled interleukin-2: One site of cancer spread in metastatic renal cell cancer is the lungs. Administering interleukin-2 as a spray that is inhaled into the lungs has been shown to stabilize cancer progression in patients with lung metastases from renal cell cancer. Over half of patients treated with inhaled interleukin-2 had stable disease. On average, patients were free of cancer progression for nearly nine months after treatment.[16]

Thalidomide plus interleukin-2: Thalidomide has been shown to cause anticancer effects in several ways, including preventing or reducing the production of blood vessels that serve the cancer cells, thereby starving the cancer of the nutrients and oxygen they need to survive and grow. As initial treatment for metastatic renal cell cancer, the combination of thalidomide plus interleukin-2 has been shown to partially shrink cancer in approximately one-quarter of patients and stabilize disease in 15% of patients.[17] Researchers continue to evaluate thalidomide in the treatment of renal cell cancer.

Vaccines for Renal Cell Cancer

Vaccines are comprised of proteins that stimulate the immune system to destroy foreign substances in the body, such as bacteria. Vaccines are also being developed that stimulate the immune system to recognize cancer cells as harmful and destroy them. Cancer vaccines are typically made from proteins that are more abundantly present on cancer cells than normal cells. The patient’s own cancer cells are often used to make the vaccine, which is one reason that vaccines may be difficult to prepare. The patient's cancer cells must be processed immediately following surgery. Therefore, patients and their surgeons must prepare in advance to ensure that the removed cancer cells can be handled properly for vaccine preparation.

A vaccine comprised of cells from the patient’s cancer has been shown to improve progression-free survival compared to surgery alone in the treatment of patients with renal cell cancer. Nearly three-quarters of the patients treated with the vaccine survived approximately six years or more compared with 59% of those treated with surgery alone. This research is ongoing.[18]

Laparoscopic Surgery

Laparoscopic surgery is a technique that is less extensive and invasive than traditional, open surgery. During a laparoscopic surgery for renal cancer, the surgeon makes small, one-centimeter incisions in the abdomen and side. A very small tube that holds a video camera is inserted to create a live picture of the inside of the patient’s body. This picture is continually displayed on a television screen, allowing the surgeon to perform the entire surgery by watching the screen. For a radical nephrectomy, the incision is enlarged to allow passage of the kidney.

In the treatment of metastatic renal cell cancer, laparoscopic surgery appears to be associated with less blood loss, fewer transfusions, and shorter hospitalization compared to open nephrectomy. In addition, there were no increases in complications with laparoscopy and patients were able to proceed with systemic therapy with this approach.[19]

References

[1] National Comprehensive Cancer Network. NCCN Announces Important Updates to Kidney Cancer Clinical Practice Guidelines. March 7, 2006. Available athttp://www.nccn.org/about/news/newsinfo.asp?NewsID=67. (Accessed August 3, 2006).

[2] Flanigan RC, Salmon SE, Blumenstein BA et al. Nephrectomy followed by interferon alfa-2b compared with interferon alfa-2b alone for metastatic renal-cell cancer. New England Journal of Medicine. 2001;345:1655-9.

[3] Mickisch GH, Garin A, van Poppel H, de Prijck L, Sylvester R. Radical nephrectomy plus interferon-alfa-based immunotherapy compared with interferon alfa alone in metastatic renal-cell carcinoma: a randomized trial. Lancet. 2001;966-70.

[4] Friedel G, Hurtgen M, Penzenstadler M et al. Resection of pulmonary metastases from renal cell carcinoma. Anticancer Research. 1999;19(2C):1593-1596.

[5] Fyfe G, Fisher RI, Rosenberg SA, et al. Results of treatment of 255 patients with metastatic renal cell carcinoma who received high-dose recombinant interleukin-2 therapy. Journal of Clinical Oncology. 1995;13(3):688-696.

[6] George D, Motzer R, Rini B, et al. Sunitinib malate (SU11248) shows antitumor activity in patients with metastatic renal cell carcinoma: updated results from Phase II trials. Proceedings from the 2005 annual Chemotherapy Foundation Symposium. New York, NY. Abstract #18.

[7] Motzer RJ, Hutson TE, Tomczak P et al. Phase III randomized trial of sunitinib malate (SU11248) versus interferon-alfa (IFN-α) as first-line systemic therapy for patients with metastatic renal cell carcinoma (mrcc). Presented at the 2006 ASCO Annual Meeting. Abstract #LBA3.

[8]Escudier B, Eisen T, Stadler WM et al. Sorafenib in advanced clear-cell renal cell cancer. New England Journal of Medicine. 2007; 356:125-34.

[9] Bukowski RM, Eisen T, Szczylik C et al. Final results of the randomized phase III trial of sorafenib in advanced renal cell carcinoma: survival and biomarker analysis. Presented at the 2007 Annual Meeting of the American Society of Clinical Oncology, Chicago, IL. Abstract 5023.

[10]Hudes G, Carducci M, Tomczak P, et al. Temsirolimus, interferon alfa, or both for advanced renal cell carcinoma. New England Journal of Medicine. 2007; 356:2271-2281.

[11] Lipton A, Zheng M, Seaman J. Zoledronic acid delays the onset of skeletal-related events and progression of skeletal disease in patients with advanced renal cell carcinoma. Cancer. 2003; 98(5):962-969.

[12] Escudier B, Koralewski P, Pluzanska A et al. A ransomized, controlled, double-bline phase III study (AVOREN) of becacizumab/interferon-α2a vs placebo/interferon-α2a as first-line therapy in metastatic renal cell carcinoma. Presented at the 43nd Annual Meeting of the American Society of Clinical Oncology; Chicago, IL 2007. Abstract #3.

[13] Sosman JA, Flaherty K, Atkins MB, et al. A phase I/II trial of sorafenib (S) with bevacizumab (B) in metastatic renal cell cancer patients. Presented at the 42nd Annual Meeting of the American Society of clinical Oncology; Atlanta, GA, 2006. Abstract #3031.

[14] Azad NS, Posadas EM, Kwitkowski VE, et al. Increased efficacy and toxicity with combination anti-VEGF therapy using sorafenib and bevacizumab. Presented at the 42nd Annual Meeting of the American Society of Clinical Oncology; Atlanta, GA, 2006. Abstract #3004.

[15] Rixe O, Bukowski RM, Michaelson MD et al. Axitinib treatment in patients with cytokine-refractory metastatic renal-cell cancer: a phase II study. Lancet Oncology. 2007;8:975-84.

[16] Merimsky O, Gez E, Weitzen R, et al. Targeting pulmonary metastases of renal cell carcinoma by inhalation of interleukin-2. Annals of Oncology. 2004;15:610-612.

[17] Amato RJ, Morgan M, Rawat A. Phase I/II study of thalidomide in combination with interleukin-2 in patients with metastatic renal cell carcinoma. Cancer. 2006;106:1498-506.

[18] Jocham D, Richter A, Hoffmann L, et al. Adjuvant autologous renal tumour cell vaccine and risk of tumour progression in patients with renal-cell carcinoma after radical nephrectomy: phase III, randomized controlled trial. The Lancet. 2004; 363:594-599.

[19] Eisenberg MS, Meng MV, Master VA et al. Laparoscopic versus open cytoreductive nephrectomy in advanced renal-cell carcinoma. J Endourol 2006 Jul;20(7):504-8.

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E&OE - Errors & Omissions Excepted