Is Surgery Necessary in Metastatic Kidney Cancer?

Of all renal cell cancers, 20% are metastatic (stage 4) at diagnosis. Removing the cancerous kidney is a standard treatment for metastatic kidney cancer if the patient’s general condition allows it. With effective treatments available, the question "Could targeted drugs alone be sufficient without surgery?" remains on our minds. CARMENA, a phase-3 clinical trial evaluating this question, was presented at the ASCO 2018 Congress.

The study assessed 450 patients, comparing sunitinib (Sutent) alone with sunitinib after surgery. Overall survival was 5 months longer in patients receiving sunitinib alone. The rate of benefit from treatment (clinical benefit) was also 14% higher in those receiving sunitinib alone.

The study was published in the prestigious oncology journal New England Journal of Medicine (NEJM) on the same day it was presented. Although it may affect our daily practice, most enrolled patients had poor-risk factors for renal cell cancer. We already do not consider surgery first in this patient group because of the burdens it imposes. In addition, locally advanced tumors were 20% more frequent among patients undergoing surgery (T4 or T3 tumors in 70% of the surgery group versus 51% of the sunitinib-only arm). Of the patients who underwent surgery, 17% never received sunitinib. Some patients could not access the drug, and all these factors explain the poorer survival of those undergoing surgery.

Although news sites emphasize these results as a practice-changing study , we believe its weaknesses mean it cannot adequately answer such an important question.

When planning treatment for our patients diagnosed with metastatic kidney cancer, we need to think individually and assess risk score, the treatment plan based on general performance status, and suitability for surgery. We believe there should not be a single treatment approach for everyone. Looking ahead, we should await studies evaluating surgery together with newly developed immunotherapies that have demonstrated success in renal cell cancer.

• Rare kidney tumors 
• current treatments
• The immunotherapy combination nivolumab and ipilimumab received FDA approval for kidney cancer treatment
• Preventive treatment after kidney cancer surgery received FDA approval for the first time