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Host:  Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And today, we're discussing advanced kidney cancer management. Joining me is Dr. Padraic O'Malley. He's an assistant professor in the Department of Urology at the University of Florida College of Medicine.

Dr. O'Malley, it's a pleasure to have you join us today. Before we get into some of the treatment options, tell us a little bit about the prevalence of kidney cancer. What have you been seeing in the trends lately?

Dr. Padraic O’Malley: Kidney cancer is a very common type of cancer. It's in both men and women. It's one of the top 10 most common malignancies. And interestingly is that the incidence of kidney cancer has continued to rise over time. A large bit of that was because we are imaging people a lot more often now for other reasons. But even when you control for that, the incidence of kidney cancer continued to rise. And we're not sure why that is yet, but it is a very common type of cancer that we encounter.

Host: So then let's talk about advanced kidney cancer management. How do you utilize various modalities, surgery, radiation, medical oncology therapies in this type of advanced kidney cancer care?

Dr. Padraic O’Malley: This is one area I'm very interested in. And I think part of my interest, not only clinically, but just as far as how we approach it comes from my interest outside of medicine and sports. I've always been an avid sports fan and sport require you, many of them, to be part of a team and be a team member and play different roles.

Traditionally in medicine, patients with localized disease, as long as they didn't have spread elsewhere, were treated primarily with surgery alone. And then those patients who had spread that were outside, say the kidney to other areas of the body were treated primarily by medical oncologists with systemic drugs. And so they were treated by independent silos of physicians. It wasn't really a very team-oriented approach to cancer care and patient care. And what we've come to realize in the last few years in the last 5 to 10 to 15 years, is that having a team-based approach where we use multiple modalities of treatment in combination or in sequence actually is the better outcomes amongst patients with not just advanced kidney cancer, but many other malignancies as well.

Host: So then let's talk about that. Given the complexity and with increasingly complex treatment algorithms that are adding new options to your armamentarium of available therapies, expand a little bit more on that multidisciplinary approach. How do you all work together? And really, who's in charge of guiding patient care?

Dr. Padraic O’Malley: So we use a sort of standardized approach for many of these patients. It's a combination of using the sort of best practice, which is mainly based on national and international guidelines, particularly those provided by the NCCN or national cancer groups. And then we also use clinical trials. The only way we know the answers to many of our clinical questions is if we test those hypotheses. And the best way to do that, generally speaking, is through clinical trials. That allows us to know how to treat patients with advanced disease better in the future. So we use a combination of clinical trials, a combination of standard guidelines to make sure we're doing the best treatment for patients.

And then in order to put that sort of into effect or an action, we often use a number of different strategies. We have a group meeting every week or two weeks, which is our genitourinary tumor board, which is a group meeting with several surgeons, several medical oncologists, our radiation oncologist, our pathologists and our radiologists.

So it's a real group of experts who sit down and review each individual patient's case, blood work, pathology, imaging as well as the sort of overall health status of those patients. And by doing so, we have the input from not just one physician, but a group of physicians, all of whom have a particular area of expertise. And that gives us a more balanced approach to these patients. .

The second strategy is using clinical trials which operate on a very rigorous background rationale behind their design. So these studies are not just fancifully thought up. They are all predicated on our previous history and knowledge.

And so when they're set up, they are set up, they're more likely to succeed than not because they've been well thought out. By enrolling patients, we actually have a group meeting every week, which involves several physicians from medical oncology and urological oncology where we meet and look at potential candidates for each trial to try and optimize our patient care.

So by using those combination of strategies, we find we can really tailor care to patients individually, but also optimize the sort of multimodal treatment of these patients.

Host: So then how do you envision your research and these clinical trials you're discussing, translating to patient care? What do you see happening?

Dr. Padraic O’Malley: Yeah. So, one of the most exciting things that's happened in oncology as a whole has been the advent of immunotherapy. Immunotherapy is a form of systemic therapy. The most common type of systemic therapy many people are familiar with of course is chemo, but chemo was like a nuclear bomb. It destroys everything, including the healthy cells and the immunotherapy obviously has a more specific or targeted approach where it harnesses your body's immune system to attack these cancer cells. We've seen with the use of these in a number of malignancies a more durable and impressive response than we have with some traditional agents.

And we started using these a lot more in kidney cancer. We know from several studies that have been done, that these drugs work better than the previous standard of care, which what we'll call tyrosine kinase inhibitor. And with this group of drugs, these tyrosine kinase inhibitors, for instance, we used to see patients who had larger more advanced malignancies that had not spread elsewhere, but we knew were at high risk for having a recurrence, anywhere from 30% to 65% chance of having a recurrence. We knew many of these patients it was only a matter of time.

In these patients, we tried using these drugs after surgery to see if we could prolong their survival. And unfortunately, despite several studies, there's about five studies done, none of these showed an overall survival benefit. And only one of them actually showed an improvement as far as how long it took before patients' disease recurred.

We know the immunotherapy drugs work better in the metastatic setting. And we're currently doing trials now in the field to determine can these immunotherapy drugs, which we know work better, maybe work better in this setting where patients have large volume disease that hasn't spread elsewhere. Can we prevent them from having recurrence? And so those are the trials that are undergoing. And actually all of those trials have finished accruing within the last year because there was such a popularity with them, because we really feel like these are likely to change management for our patients on the trial as well as for our future patients.

Host: It's such a fascinating and exciting time to be in this field, Dr. O'Malley. And as you've been telling us about immunology, what about some of the most exciting advanced surgical technologies? Is there anything, whether it's intraoperative, radiologic imaging or anything exciting you'd like other providers to know about?

Dr. Padraic O’Malley: Yeah, I think one of the biggest changes in surgical management in all fields has been the advent of minimally invasive surgery. It first began with laparoscopic surgery and now with robotic surgery. Certainly, there were some patients we were able to do laparoscopic surgery on before, but the advent of robotic surgery has really allowed us to do more complex cases. So in patients who have smaller lesions, we can preserve their kidney function by only doing a partial nephrectomy, only taking part of a kidney. And the nice thing about doing that robotically is we can do more complex lesions this way. And patient's recovery time is much quicker. So that's always a benefit for patients and their ongoing day-to-day care.

In the advanced kidney cancer setting, what we're starting to see is a greater utilization of robotic techniques in advanced cases. So one thing we started doing a lot more at the University of Florida is some patients with these advanced types of cancers in the kidney, the tumor will actually start growing along the vein of the kidney and will eventually grow into what's called the inferior vena cava, which is the largest vein that drains the majority of the blood from your lower body and some abdominal organs.

And traditionally, when this happens, this is a big open operation, which requires five to seven-day hospital stay and a fairly large incision most often times. We've actually started doing these robotically. And what we found is that most patients are ready to go home either the day after or the next day and the recovery time is much quicker. So it allows patients not only to get back to what they liked doing quicker, it leads to less of a disruption to quality of life. And it allows them to potentially go on to other therapies should they require them quicker. So we've seen a big change in how long a patient would need to recover with using this technology.

Host: As we wrap up, and again, this is so interesting, do you have anything else you would like to inform other providers about when we're talking about advanced kidney cancer management?

Dr. Padraic O’Malley: Yeah. I think whether you're a primary care physician, a urologist or someone who's incidentally seen someone with a larger renal mass or potentially spread to other organs or to the lymph nodes or to the chest, I think those are the type of patients that we are best managed by providers at high-volume centers who have I'd say more than the expertise of resources.

There are excellent surgeons in many hospitals. But what allows us, I think, to optimize care for these patients is the resource that exists in academic or tertiary care centers, where we can pull in the expertise from medical oncology and radiology. And so many providers out in community care setting may not have access to those resources readily. Their system's not set up for that. They're fine surgeons. It's just that the focus of what they do is not this.

And so I think if you're looking at these patients and you want to optimize their care, I think these patients are best seen at these centers that you do offer clinical trials and do have a multidisciplinary approach to these patients. And I think your patients will thank you for it. And I think you'll be happier with how they do long-term as well.

Host: That's great information, Dr. O'Malley. Thank you so much for joining us today. And to refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters.

That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other UF Health Shands Hospital podcasts. I'm Melanie Cole.