Professor Bernard Escudier – Institut Gustave Roussy, Paris, France
How to select targeted therapy in renal cancer
What were you talking about at ESMO 2010?
I’ve been asked to explain to the candidates how I select patients for targeted therapy in renal cancer. So what I tried to do in this talk was to bring people from clinical cases to should they treat the patients, should they think about surgery in a specific patient? How should they select surgical therapy depending on the histology, depending on the lines of treatment they were in? Any other comorbidities, age and so on. That was my focus and I think it was a little different because I did not approach the talk by giving all the data from the phase III but mainly on trying to explain to the people here what we have to do when we see a patient in front of us.
What were the key points?
The first thing, I think, in front of kidney cancer, the first question we have to ask is whether we should treat or not to treat a patient. Even the metastatic patients in kidney cancer, this is a specific disease where we have some very slow progressive disease and we have to discuss not to treat a patient with slow progressive disease because we know that these patients can stay like that, without any treatment, for years. And when you have to put it in the balance, a conic treatment and something which is not treatment, no expense, no toxicity, you have really to think about that and we are not sure that in this specific group of patients we are going to prolong survival with treatment. Plus we don’t know if starting a treatment earlier in the course of this kind of disease is useful or not.
The second point we really have to discuss in front of kidney cancer is should we propose patient surgery. Of course when we have the primary tumour in place but also in the course of the disease we have now showed that using surgery to put the patients free of disease at any stage is very important and we have really to think about surgery in the management of metastatic kidney cancer.
Then I tried to put the people in the room in front of the patients in front line and in front of the patients in second line, then trying to demonstrate to them that even in third or fourth line kidney cancer, with all the drugs we have now, we can really help the patients prolong survival and we have a very selective group of patients where we can give up to four fourth line or fifth line treatments with really a very long survival.
Are you advocating less surgery overall?
Yes, on the one hand some people are over treated and I showed in my presentation several cases where I decided not to treat and, in fact, for two, three or five years even. I presented patients for five years without any increase in the lung metastases. So this does exist in kidney cancer and we have to give the chance to patients before starting the treatment, just to check that they are not in the situation not to progress without any treatment.
What would be your message to patients diagnosed with renal cancer?
That was another message from my talk, is that we have to explain to the patients what we are going to do if we treat them. We are going to start the treatment and we are going to start the treatment for ever and that’s actually what we do when we start a treatment in kidney cancer. We have to explain the toxicity of the treatment, the expected benefit of the treatment and then to put in balance all the toxicity etc in front of the quality of life, in front of the expected survival without any treatment. Obviously it’s not the same if you are a 50 year old or if you are a 70 or 75 year old. The way you can think about your life, your desire and so on might be very different.