A roundtable discussion, moderated by Brian Rini, MD, addressed considerations for clear versus nonclear cell kidney cancer, as well as recent data from ESMO 2023. Dr. Rini was joined by Tian Zhang, MD; David McDermott, MD; and Hans Hammers, MD.
In the final segment of the roundtable series, the panel discusses excitement for the future in kidney cancer: CAR-T, adjuvant checkpoint inhibitors, and sequencing.
Dr. Rini: One last topic for each of you. What are you most excited about? Could be a study; it can be an approach. I’m sure, David, yours is going to be a biomarker. We’ll go Hans will start first. If you said this is the 1 thing that’s going to transform kidney cancer in the next 3 to 5 years.
Dr. Hammers: Well, transform kidney cancer…
Dr. Rini: Or have the biggest impact.
Dr. Hammers: I’m all about new targets. I would say principally what I’m really excited about to see, and that’s just not in kidney cancer, is actually CAR [chimeric antigen receptor] T cells in solid tumors. That’s something that I think we all were very skeptical how they would translate from leukemias into solid tumors. Certainly, a much more challenging approach. But we do have early-phase clinical trials targeting CD70 where we do see some responses. Again, not yet as durable and beneficial as we want them to be, but there will be much more fine-tuning of these cells. I think cellular therapy in kidney cancer is going to come and will be CAR T cells, NK cells. I think the future is bright in that regard and so I’m sending more and more patients to some of those trials.
Dr. Rini: Great. David?
Dr. McDermott: I think in that timeframe, the next 5 years, I think the adjuvant application of checkpoint is probably the biggest outcome changer for our patients. But we have to insist on selection there. Now that we’ve seen a whiff of OS [overall survival], hint of OS in the press release from Merck to get into that data, find out what’s driving that overall survival signal. The fact that they saw overall survival is impressive. We haven’t seen that in melanoma. We haven’t seen that in lung cancer. It’s a big deal.
Dr. Rini: Why do you think it’s different? I know we haven’t seen the data yet, so it’s an impossible question. But you also do melanoma, so if you don’t see it in melanoma, the most immune-responsive tumor.
Dr. Hammers: The big difference, if I may just interject. What I see is that the melanoma trial was actually really well-designed. What Dr. Eggermont insisted on is that anyone who was on the adjuvant trial got access to pembrolizumab no matter where you lived. What we keep forgetting is similar to China and other countries, there will be large swaths of populations who participate in these trials who will never get access to immunotherapy. A clinical trial like that doesn’t necessarily boil down to immunotherapy early versus immunotherapy late. It boils down to immunotherapy early versus only 40% of patients getting immunotherapy on the other arm.
Dr. Rini: In the melanoma trial, how many patients got salvage immune therapy?
Dr. McDermott: Almost everyone.
Brian Rini: Almost everyone. But we don’t know that for KEYNOTE, right?
Dr. Hammers: It was not guaranteed.
Dr. Rini: Right. I didn’t know if it was collected and there was a number, I don’t remember one.
Dr. McDermott: That would be 1 explanation. Another is you’re preventing death in the worst out the most aggressive tumors, which to me that suggests we should treat based on, once again, the tissue, not on the clinical stage. I think we can figure it out. I want to believe we can figure this out. We have to insist, just because sucked up to this point with biomarkers doesn’t mean we have to be the only area of oncology where it doesn’t have … We’re pretty lame when it comes to those. We can do better.
Dr. Rini: Agreed. On that note, Tian?
Dr. Zhang: And to add, I think it is very much a shared decision-making time point for patients. If we are impacting disease-free survival, now in the press release, we’re impacting overall survival. But who is accepting of those toxicities, potentially, their tumor is removed, so their toxicities are all from drug. I think there’s a lot there that we can mine in terms of thinking through how do we make these risk-benefit calculators more patient friendly and to drive that shared decision-making conversation. To your earlier question about what we’re excited about, I have to say PDIGREE is enrolling extremely well. It’s this adaptive approach. We’re probably going to finish enrollment in the coming year, so I’d be very hopeful that we’ll actually read out a cooperative group study that will be meaningful.
Dr. Rini: Me as well. I’ll just add, and we’ll end on this, I’ll channel my Dave McDermott here, I think there’s other checkpoint inhibitors and other immune therapy, LAG-3 inhibition and others, that we haven’t really developed. I do think the way to cure patients is to stack immune therapies upfront. As much as I love TKIs, I think that’s really where, if we want to talk about truly impacting patients and curing a fraction and not having beyond chronic therapy, even intermittent etc., which I’ll admit is less than ideal. I think that’s where we’ll go. Hopefully we’ll see some of those data. Thank you all for joining. Appreciate the lively discussion. There was a little too much agreement for me on this panel, but I appreciate all of you and thanks to our audience for joining the GU Oncology Now RCC Roundtable.