Page 19 - CUA KIDNEY CANCER HANDBOOK 2020

Advanced/Metastatic Kidney Cancer
Management Algorithm: Clear-cell Carcinoma

Advanced or Metastatic Kidney Cancer: Clear-cell Carcinoma

Refer to oncology specialist in multidisciplinary environment

Conduct risk stratification using IMDC criteria

Assess eligibility for cytoreductive nephrectomy
De novo mRCC, ECOG≤1 or KPS ≥80%, Significant systemic symptoms
minimal symptoms related to metastases, from metastatic disease, active CNS
resectable primary tumor, limited burden metastases, limited burden of disease
of metastatic disease; where systemic within kidney relative to cumulative
therapy is not urgently required extra-renal volume of metastases, rapidly
progressing disease, ECOG >1 or
KPS <80%, and/or limited life expectancy
Cytoreductive nephrectomy,
followed by active surveillance if
favourable- or intermediate-risk per
a
IMDC; otherwise followed by metastases-
directed therapy or systemic therapy

Consider systemic treatment options based on IMDC risk
IMDC favourable-risk IMDC intermediate-risk IMDC poor-risk
0 criteria 1-2 criteria 3-6 criteria

Untreated Untreated
Preferred options: Preferred:
Axitinib + Pembrolizumab b Ipilimumab + Nivolumab OR
Axitinib + Pembrolizumab b
c,e
Other options: Sunitinib or Pazopanib OR Other options: Axitinib + Avelumab OR
f
c
Axitinib + Avelumab OR Cabozantinib OR
High-dose IL-2 OR Sunitinib or Pazopanib OR
d
Active surveillance Active surveillance
Monitoring:
• Provide patients/caregivers with information concerning potential side effects,
prevention, and management
• Evaluate patients frequently to ensure early recognition and management of toxicities

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Practical Approaches to Managing Advanced Kidney Cancer 13