Is there a "Trial Effect" on Outcome of Patients with Metastatic Renal Cell Carcinoma Treated with Sunitinib?

Management of Patients With Metastatic Renal Cell Cancer and Bone Metastases

BACKGROUND/AIM

Previous research has suggested that patients with metastatic renal cell cancer (mRCC) and bone metastases have a poorer prognosis compared to their counterparts with no skeletal involvement. Therefore, we analyzed the management and outcomes of such patients in our center.

PATIENTS AND METHODS

We performed a retrospective study of 35 consecutive patients who received systemic treatment, largely targeted therapy, for mRCC with bone metastases.

RESULTS

The median overall survival was 25 months from the time of diagnosis of mRCC. The 5-year survival rate was 16%. Survival from diagnosis of mRCC was significantly worse in patients with bone metastases present at the start of first-line systemic therapy (median 13 months) compared to delayed metastases diagnosed later during the course of disease (46 months, p=0.01). Few patients (29%) were able to receive more than two lines of systemic therapy. Bone-only metastases were uncommon (11%).

CONCLUSION

Most patients with mRCC and bone metastases have limited overall survival.

Clinical characteristics and outcomes of patients enrolled in clinical trials compared with those of patients outside clinical trials in advanced gastric cancer

AIMS

Participating in clinical trials could give cancer patients potential benefits such as experimental treatment, meticulous follow-up, and management of toxicities. We hypothesized that patients participating in clinical trials would achieve better survival outcomes than those not enrolled in trials. We assessed whether the trial effect can improve survival for patients with advanced gastric cancer.

METHODS

We retrospectively enrolled metastatic or recurrent gastric cancer patients who received palliative chemotherapy from January 2010 to December 2012. All patients in this study received fluoropyrimidine and platinum as the first-line palliative chemotherapy. Patients participating in clinical trials were matched 1:1 with patients not enrolled in trial based on propensity-score.

RESULTS

A total of 229 patients were identified, 83 (36.2%) among them participated in 14 clinical trials for advanced gastric cancer. The number of patients enrolled in phase I, II and III trials were 10, 54 and 19, respectively. The median overall survival of the total study patients was 13.0 months (95% confidence interval, 10.7-15.3 months). In the propensity-score matched population, a total of 78 matched pairs of patients were generated. The median overall survival of the 78 patients who participated in the clinical trials was 6 months longer than that of patients not enrolled in trials, although this benefit was marginally significant (15 months vs 9 months, hazard ratio, 0.709; p = 0.068). Participation in clinical trials was a significant factor to predict better overall survival in multivariate analysis (hazard ratio, 0.533, p = 0.001).

CONCLUSION

Trial effect may contribute to prolongation of overall survival in patients who participate in clinical trials for advanced gastric cancer. Physicians may discuss trial effect to encourage participation in clinical trials.

Eligibility for phase 3 clinical trials of systemic therapy in real-world patients with metastatic renal cell cancer managed in a rural region

Previous research has identified disparities between urban and rural cancer care, including clinical trial access. Therefore, we addressed three different questions in patients with metastatic renal cell cancer managed according to national guidelines in a rural Norwegian standard practice setting. (1) How many patients would have been eligible for three recent landmark randomized clinical trials? (2) Is survival different between eligible and non-eligible patients receiving first-line systemic therapy? (3) Is survival different between eligible patients and published trial results? We performed a retrospective analysis of 101 consecutive patients (2006-2016). Only 52% of the patients were eligible for the first-line study of pazopanib versus sunitinib. The main reasons for violating inclusion or exclusion criteria were presence of brain metastases, absence of clear cell histology, and poor performance status. Even fewer patients were eligible for trials of nivolumab and cabozantinib in pre-treated patients. Eligible patients had significantly better survival than non-eligible patients, median 29.2 versus 8.5 months (p = 0.0001). These results confirm that many patients from rural practices do not fulfill all mandatory trial eligibility criteria. However, eligible patients managed according to national guidelines had survival outcomes in line with published first-line trial results.

Assessment of ethnic differences in sunitinib outcome between Caucasian and Asian patients with metastatic renal cell carcinoma: a meta-analysis

BACKGROUND

An increasing number of studies have reported ethnic differences in sunitinib outcome in metastatic renal cell carcinoma (mRCC) patients. However, a comprehensive analysis is still lacking. Therefore, we systematically collected available published data and performed a meta-analysis to compare sunitinib efficacy and toxicity in Asian and Caucasian mRCC patients.

METHODS

Data were extracted from published results from clinical trials, expanded access program and real-world clinical practice. Progression-free survival (or time to tumor progression), overall survival, objective response rate and adverse events were used as endpoints to evaluate the differences of sunitinib outcome between the two ethnicities. For adverse events, we focused the following clinically relevant side effects: diarrhea, fatigue, mucositis/stomatitis, hand-foot syndrome, hypertension, leukopenia, neutropenia and thrombocytopenia.

RESULTS

A total of 33 publications including 9977 patients were available for meta-analysis. The efficacy of sunitinib in Asian patients was similar to that in Caucasian patients. However, Asian patients showed a higher incidence of all grades toxicity of hand-foot syndrome, > grade 2 fatigue, > grade 2 hand-foot syndrome and > grade 2 thrombocytopenia.

CONCLUSION

Ethnic differences in adverse events of sunitinib in mRCC patients existed and dose adjustment in Asian patients may be considered.

Long-term response to sunitinib: everolimus treatment in metastatic clear cell renal cell carcinoma

AIM

The study aim was to evaluate progression-free survival (PFS) and overall survival (OS) in patients with metastatic clear cell renal cell carcinoma on sunitinib (SU) and SU-everolimus treatment.

PATIENTS & METHODS

After 7 years of enrollment and 9 years of follow-up, 193 consecutively presenting patients (151 men and 42 women) were treated.

RESULTS

A total of 157 patients (81.3%) died and 36 patients (18.7%) survived. Median PFS in 193 SU-treated patients was 14.7 months and OS was 28.8 months. Median PFS was 13.98 months and median OS was 26.67 months in 175 patients treated with SU only or on SU-everolimus.

CONCLUSION

The development of SU-induced hypothyroidism, hypertension, neutropenia and edema was a significant predictive and prognostic factor.

Decreased expression of RASSF1A tumor suppressor gene is associated with worse prognosis in clear cell renal cell carcinoma

Clear-cell renal cell carcinoma (ccRCC) is the most common subtype of RCC (70-80%) and is associated with poor prognosis in 40% of cases mainly due to metastasis in the course of the disease. RASSF1, with its isoforms RASSF1A and RASSF1C, is a tumor suppressor gene which has not been fully analyzed in ccRCC yet. The epigenetic downregulation of RASSF1A is commonly associated with promoter hypermethylation. The aim of the present study was to compare the ccRCC outcomes with the expression of RASSF1A and RASSF1C. Tissues were obtained from 86 ccRCC patients. RASSF1A and RASSF1C mRNA levels were assessed in tumor and matched normal kidney tissue, and in 12 samples of local metastases by quantitative PCR (qPCR). RASSF1A and RASSF1C proteins levels were semi-quantified in 58 samples by western blot analysis and their tissue localization was assessed by immunohistochemistry. Hypermethylation of RASSF1A promoter was measured by high-resolution-melting methylation-specific qPCR. RASSF1A mRNA levels were 4 and 5 times lower in 66% of tumor and 75% metastasized samples. RASSF1A hypermethylation was found in 40% of analyzed T cases. RASSF1A protein expression was 5 or 20 times decreased in 70% tumor and 75% metastatic samples, respectively. RASSF1A hypermethylation, mRNA and protein levels were associated with TNM progression and higher Fuhrman's grading. Decreased RASSF1A expression, hypermethylation, TNM and Fuhrman's grading were associated with poorer overall survival (OS). Cox hazard ratio (HR) analysis revealed predictor role of RASSF1A mRNA levels on OS and progression-free survival (PFS) in relation to Fuhrman's grading (OS HR=2.25, PFS HR=2.93). RASSF1C levels were increased in ccRCC; no correlations with clinicopathological variables were found. We conclude that RASSF1C gene is not involved in ccRCC progression and we propose that the measurements of RASSF1A mRNA levels in paired tumor-normal kidney tissue could serve as a new prognostic factor in ccRCC.