Addressing resistance to PD-1/PD-(L)1 pathway inhibition: considerations for combinatorial clinical trial designs

With multiple PD-(L)1 inhibitors approved across dozens of indications by the US Food and Drug Administration, the number of patients exposed to these agents in adjuvant, first-line metastatic, second-line metastatic, and refractory treatment settings is increasing rapidly. Although some patients will experience durable benefit, many have either no clinical response or see their disease progress following an initial response to therapy. There is a significant need to identify therapeutic approaches to overcome resistance and confer clinical benefits for these patients. PD-1 pathway blockade has the longest history of use in melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). Therefore, these settings also have the most extensive clinical experience with resistance. In 2021, six non-profit organizations representing patients with these diseases undertook a year-long effort, culminating in a 2-day workshop (including academic, industry, and regulatory participants) to understand the challenges associated with developing effective therapies for patients previously exposed to anti-PD-(L)1 agents and outline recommendations for designing clinical trials in this setting. This manuscript presents key discussion themes and positions reached through this effort, with a specific focus on the topics of eligibility criteria, comparators, and endpoints, as well as tumor-specific trial design options for combination therapies designed to treat patients with melanoma, NSCLC, or RCC after prior PD-(L)1 pathway blockade.

Prevalence of dietary modification and supplement use in patients with metastatic renal cell carcinoma (mRCC)

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Background: Mounting data suggests that dietary modification and supplement use, including probiotics, may modulate outcomes with immunotherapy in cancer therapy (Spencer CN et al. Science 2021; Dizman N et al. Nature Medicine 2022). For the first time, we sought to quantify the use of these measures among patients with metastatic renal cell carcinoma (mRCC). Methods: An online survey was administered by Kidney Cancer Research Alliance (KCCure), a non-profit patient advocacy group, between July 22 and Sept 22 to a patient mailing list (N=1,532). Only patients diagnosed with mRCC and under active systemic therapy were included for analysis in the current study. Select questions were directed at dietary modification patterns and supplement usage. Patients were additionally surveyed regarding out-of-pocket spending patterns related to supplement purchases and to what extent they shared information about their supplement intake with their physicians. The student's t-test and Chi-square test were used to compare sociodemographic characteristics between participants who did and did not report supplement intake. Results: Out of 1,062 patients with renal cell carcinoma who participated in this survey, 289 met the inclusion criteria (M:F, 145:143). The median age was 61. The majority of patients identified themselves as white (91%), were from the US (86.8%), and had completed a bachelor's degree (52.9%). 21.1%, 46.1%, and 32.6% lived in urban, suburban, and rural locations, respectively. The most common reported first-line treatments were nivolumab/ipilimumab (32.4%) and axitinib/pembrolizumab (13.1%). 22.4% of respondents reported spending >$100/month on supplements, and 8.3% reported spending >$250/mo. Dietary modifications following a cancer diagnosis were reported by 34.9% of respondents, out of which 19.8% followed the Mediterranean diet and 18.8% adopted a ketogenic diet. 50.8% of respondents reported supplement intake. The most widely utilized supplements were cannabidiol (CBD) oil/marijuana, probiotics, and Vitamin C, reported by 28.0%, 24.2%, and 18.6% of respondents, respectively. 83.4% of respondents noted that they consistently report supplement usage to their physicians. There were no statistically significant associations between supplement use and age, sex, living area, or education. Conclusions: A substantial proportion of patients with mRCC use dietary modification and supplements as an adjunct to their antineoplastic treatment. Interventions such as probiotic use and ketogenic diets, which are the subject of a prospective study in mRCC (NCT05119010; NCT05122546), may already be used by many patients. More careful attention to nutrition and supplement use in clinical trial candidates may minimize the impact of these potential confounders.

Patient perceptions of benefits and risks of adjuvant therapy in renal cell carcinoma

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Background: Adjuvant treatment with the immune checkpoint inhibitor (CPI) pembrolizumab and the tyrosine kinase inhibitor (TKI) sunitinib are currently standard of care options for patients with high-risk localized renal cell carcinoma (RCC). However, treatment decisions need to be based on anticipated benefit, toxicity risk, and patient goals and values, particularly since multiple trials testing CPIs and TKIs in the adjuvant setting did not meet their primary endpoints. To improve patient selection and communication, we sought to assess how patients perceive the benefits and risks of adjuvant therapy. Methods: The survey was developed by the Kidney Cancer Research Alliance (KCCure), with multidisciplinary representation from urologic surgeons, medical oncologists and patient advocates. The survey was broadcast between 07/2022 and 09/2022 to patients via website, mailing lists and social media platforms. Out of 1,062 participants 639 patients self-identified with localized RCC and 223 patients had stage 3 RCC at initial diagnosis. 113 patients were offered adjuvant therapy by their doctor, 74 patients reported being treated with or having received treatment with adjuvant therapy (18% treated with TKI, 82% with CPI). Results: When asked to assess risk of recurrence, patients with stage 3 disease assessed their average personal risk to be 47%, 10% higher than what they reported their doctor assessed risk to be (37%). When asked to identify the most important factors related to adjuvant decision making, patients ranked risk of dying from cancer (76%) over severity of possible side effects (43%), chance of having side effects (35%), time required for treatment (24%), and cost of treatment (7%). 49% of patients offered adjuvant therapy believe that treatment reduces the risk of recurrent disease by more than 30% and 25% believe it reduces risk by more than 50%. Among patients receiving or having received adjuvant therapy, 46% completed adjuvant therapy, 17% stopped early due to side effects and 14% recurred while on therapy. Side effects were asymptomatic or mild in 38%, moderate without invasive intervention or hospitalization in 48% severe, requiring hospitalization in 8% and life-threatening in 7%. 22% of patients were told that their side effects would be life-long. Conclusions: Patients with high-risk localized disease estimate their recurrence risk to be higher than what their doctors assess their risk to be. When weighing decisions about adjuvant therapy, patients rank risk of dying from cancer over risks related to toxicity. An overestimation of benefits of adjuvant therapy is noted with one quarter of patients believing that adjuvant therapy will reduce their risk of recurrence by 50 percent or more. The findings highlight the importance of effective communication between patients and providers regarding the risks and benefits of adjuvant therapy to promote an informed and shared decision.

Financial toxicity in patients with metastatic renal cell carcinoma on combination therapy

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Background: Combination therapy based on immunotherapy (IO) alone or in combination with oral tyrosine kinase inhibitors (TKI) has become the standard of frontline therapy in metastatic renal cell carcinoma (RCC). We sought to ascertain real world data on financial implications in RCC patients on combination therapy. Methods: An online survey was administered by Kidney Cancer Research Alliance (KCCure), a non-profit patient advocacy group, between 07/2022 and 09/2022 to patients via website, mailing lists and social media platforms. Multiple responses from the same patient were prohibited via anonymized IP address tracking. Select questions were directed at questions related to financial concerns as well as the validated 11-item COST measure and out-of-pocket spending patterns related to supplement purchases. Pearson’s correlation (r) and Kendal’s tau test were used to analyze the COST questionnaire, financial burden and hardship. Significance levels were 2 tailed. Results: 289 responders were on combination therapy (IO+IO or IO+TKI) (M:F, 145:143). Median age was 61 (range 19-89). 177 pts answered the COST questionnaire. Patients identified themselves as white (91%), living in the US (86.8%) and had a bachelor's degree or beyond (52.9%). 21.1%, 46.1%, and 32.6% lived in urban, suburban, and rural locations. The approximate annual household income was <50.000US$ in 17%, <100,000US$ in 41% and >200,000US$ in 15%. 61% had private insurance, 27% were on Medicare/Medicaid and 0.6% were uninsured. 14% reported that it was difficult or very difficult to pay their premiums. 31% were retired and 24% not able to work. 28% reported that their medical situation has not reduced their income at all and 26% claimed that their disease reduced their income very much. Significant financial, medical, behavioral, psychological and emotional hardship was reported by 15%, 26%, 12%, 19% and 24% of the patients respectively. The monthly out of pocket costs were independent of type of therapy with 50% of the patients reporting spendings of <50US$. 36% reported high out of pocket costs are a barrier to care. 44% have received financial support through a manufacturer or a foundation.22.4% of responders reported spending >$100/month on supplements, and 8.3% reported spending >$250/mo. Median COST score was 22 (range 4-36). COST score was significantly correlated to age, NCCN distress score, time since diagnosis and supplement intake (p<0.05). Conclusions: Systemic therapy imposes financial hardship on patients but does not seem to be worse with combination therapy in RCC. Route of administration is not influencing financial hardship. Patients are willing to pay for out supplements if their treatment is not causing financial harm.

Patient perspectives on the impact of immune therapy on comorbid conditions in kidney cancer

640

Background: Immune based regimen has rapidly become the mainstay of frontline therapy in advanced RCC. The median survival is in the range of 48-55 months and long term remissions are feasible. The impact of the therapy on other health conditions has not been studied. The immune therapy toxicities can potentially be long lasting and life changing. With the conversion of advanced RCC to a chronic disease, awareness and management of these conditions is important. With the use of immune checkpoint therapy in the adjuvant setting has made this information even more critical. Methods: The survey was developed by the Kidney Cancer Research Alliance (KCCure), with multidisciplinary representation from urologic surgeons, medical oncologists and patient advocates. The survey was broadcast between 07/2022 and 09/2022 to patients via website, mailing lists and social media platforms. Multiple responses from the same patient were prohibited via anonymized IP address tracking. The comorbid conditions were collected and patient perspective on changes to any medical conditions was evaluated in the survey questionnaire. Results: Patients with metastatic disease being treated with systemic therapy were included in this survey. A total of 1062 patients responded to the survey of which 399 patients self identified as being metastatic and 289 reported to be treated with immune based systemic therapy. The table includes patient characteristics. 85% respondents were from the United States. The most common condition that developed after starting immune based therapy was thyroid dysfunction as seen in 81 patients, followed by hypertension (Htn) in 50 pts, chronic kidney disease in 23 pts, heart disease in 10 patients and diabetes mellitus (DM) in 13 pts. Immune disorders developed in 26 (10%) patients. Conclusions: There is a noteworthy incidence of medical conditions emerging as a result of immune checkpoint inhibitor therapies in RCC. This information would be a starting point for studying the long term effects of immune therapy and would lead towards development of survivorship programs for renal cancer. [Table: see text]

Decisional Regret and Financial Toxicity among Patients with Benign Renal Masses

INTRODUCTION

Treatment of benign renal masses may often be unnecessary and can lead to significant morbidity, mortality, and health care costs. However, individual burdens such as decisional regret and financial costs associated with treatment are not well understood.

METHODS

Members of a support group who have been diagnosed with benign renal tumors were surveyed to evaluate demographic and clinical characteristics as well as decisional regret, using the modified Decision Regret Scale (DRS), and financial toxicity, using the Comprehensive Score for Financial Toxicity (COST). Predictors of decisional regret (DRS score >25) and financial toxicity were explored using logistic and linear regression analyses, respectively.

RESULTS

Of 70 respondents with complete data, 49 (70%) received definitive treatment while 21 (30%) elected surveillance. Decisional regret was expressed by 34/70 (49%) of patients and was associated with increasing age, smaller tumor size, and use of surveillance vs active treatment in univariable analysis. Patients reported significant financial toxicity from the diagnosis of a benign renal mass with a median COST score of 24, similar to a historical cohort of patients with stage IV solid organ cancers undergoing chemotherapy. Qualitative analysis of patient responses identified a lack of discussion by the provider of the likelihood of benign disease, postoperative complications, and financial burden as common themes in their experiences.

CONCLUSIONS

High levels of decisional regret and financial toxicity were found among individuals with benign renal lesions regardless of treatment approach. Improved counseling and diagnostic tools may limit the psychological and financial burdens from these benign entities.

Genetic risk assessment for hereditary renal cell carcinoma: Clinical consensus statement

BACKGROUND

Although renal cell carcinoma (RCC) is believed to have a strong hereditary component, there is a paucity of published guidelines for genetic risk assessment. A panel of experts was convened to gauge current opinions.

METHODS

A North American multidisciplinary panel with expertise in hereditary RCC, including urologists, medical oncologists, clinical geneticists, genetic counselors, and patient advocates, was convened. Before the summit, a modified Delphi methodology was used to generate, review, and curate a set of consensus questions regarding RCC genetic risk assessment. Uniform consensus was defined as ≥85% agreement on particular questions.

RESULTS

Thirty-three panelists, including urologists (n = 13), medical oncologists (n = 12), genetic counselors and clinical geneticists (n = 6), and patient advocates (n = 2), reviewed 53 curated consensus questions. Uniform consensus was achieved on 30 statements in specific areas that addressed for whom, what, when, and how genetic testing should be performed. Topics of consensus included the family history criteria, which should trigger further assessment, the need for risk assessment in those with bilateral or multifocal disease and/or specific histology, the utility of multigene panel testing, and acceptance of clinician-based counseling and testing by those who have experience with hereditary RCC.

CONCLUSIONS

In the first ever consensus panel on RCC genetic risk assessment, 30 consensus statements were reached. Areas that require further research and discussion were also identified, with a second future meeting planned. This consensus statement may provide further guidance for clinicians when considering RCC genetic risk assessment.

LAY SUMMARY

The contribution of germline genetics to the development of renal cell carcinoma (RCC) has long been recognized. However, there is a paucity of guidelines to define how and when genetic risk assessment should be performed for patients with known or suspected hereditary RCC. Without guidelines, clinicians struggle to define who requires further evaluation, when risk assessment or testing should be done, which genes should be considered, and how counseling and/or testing should be performed. To this end, a multidisciplinary panel of national experts was convened to gauge current opinion on genetic risk assessment in RCC and to enumerate a set of recommendations to guide clinicians when evaluating individuals with suspected hereditary kidney cancer.

Discrepancies between genitourinary cancer patients' and clinicians' characterization of the Eastern Cooperative Oncology Group performance status

BACKGROUND

Patient-reported outcomes have been used to assess treatment effectiveness and actively engage patients in their disease management. This study was designed to describe the patient-reported performance status (PS) and the provider-reported PS.

METHODS

Patients with metastatic genitourinary cancers were recruited from a single cancer center before the initiation of a new line of treatment. PS (Eastern Cooperative Oncology Group [ECOG]), quality of life (Functional Assessment of Chronic Illness Therapy-General), and distress (Patient-Reported Outcomes Measurement Information System Anxiety and Depression) were self-reported by patients. Clinical data (eg, age, sex, diagnosis, and physician-reported ECOG PS) were extracted from medical records. Multivariate analysis was used to determine the association between PS, quality of life, and psychological symptoms.

RESULTS

One hundred forty-five patients were enrolled (76.6% male, 70.3% White, 81.4% married, and 76.6% well educated). The median age was 67 years; 66.9% were diagnosed with renal cell carcinoma, 20.0% were diagnosed with urothelial carcinoma, and 13.1% were diagnosed with prostate cancer. Clinicians more frequently classified patients' ECOG PS as 0 in comparison with the patients themselves (92.4% vs 64.1%; P = .001). Higher clinician-reported ECOG PS was associated with poorer physical and functional well-being and higher rates of depression (P < .01), whereas higher patient-reported ECOG PS was associated with worse psychosocial outcomes (P < .01).

CONCLUSIONS

Discrepancies were noted between the patient- and provider-reported ECOG PS, with clinicians overestimating the ECOG PS in comparison with the patients themselves. This study's findings suggest that patients incorporate their social and emotional well-being into their PS score in addition to their physical well-being. This information is not immediately accessible to most clinicians from just a standard patient interview and likely accounts for the overestimation of the patients' ECOG PS by the clinicians.

Fear of Cancer Recurrence in Patients With Localized Renal Cell Carcinoma

PURPOSE

Patients with cancer commonly report distress and fear of cancer recurrence (FCR) impacting quality of life and clinical outcomes. This study aims to test the association between emotional well-being and clinical characteristics of survivors with localized renal cell carcinoma (RCC).

MATERIALS AND METHODS

Survivors with localized RCC were invited to participate in this study through social media by the Kidney Cancer Research Alliance. Participants self-reported clinical characteristics, distress (Distress Thermometer), and FCR (Fear of Cancer Recurrence-7). Ordinal regression was used to test the association between emotional well-being and patient characteristics.

RESULTS

A total of 412 survivors were included in this analysis. Participants were mostly female (79.4%) and well educated (58.3%), with a median age of 54 years (range, 30-80 years) and median time since diagnosis of 17.5 months. More than one half were diagnosed with stage I disease (56.1%). Most patients (62.3%) had a clear understanding of their diagnosis. A high prevalence of moderate to severe distress (67.0%) and FCR (54.9%) was reported across all survivors of RCC. Higher FCR was associated with female gender, younger age, and lack of understanding of their diagnosis (P = .001), whereas more recent diagnosis was associated with higher distress levels (P = .01).

CONCLUSION

Our findings suggest that FCR is a common problem that is persistent after therapy and that certain individuals, including female and younger patients, may be at particular risk of experiencing clinically relevant FCR.

Counterbalancing COVID-19 with Cancer Surveillance and Therapy: A Survey of Patients with Renal Cell Carcinoma

Background

While providers are challenged with treatment decisions during the coronavirus disease 2019 (COVID-19) crisis, decision making ultimately falls in the hands of patients—at present, their perspective is poorly understood.

Objective

To ascertain renal cell carcinoma (RCC) patients’ perspectives on COVID-19 and understand the associated implications for treatment.

Design, setting, and participants

An online survey of RCC patients was conducted from March 22 to March 25, 2020, disseminated through social media and patient networking platforms. The survey comprised 45 items, including baseline demographic, clinicopathologic, and treatment-related information. Patients were additionally queried regarding their anxiety level related to COVID-19 and associated implications for their cancer diagnosis.

Intervention

An online survey study.

Outcome measurements and statistical analysis

Descriptive statistics with graphical outputs were used to characterize survey results.

Results and limitations

A total of 539 patients (male:female 39%:58%) from 14 countries responded. Of them, 71% felt that their risk of COVID-19 infection was higher than the general population, and 27% contacted their physician to establish this. Among patients with localized disease (40%), most (42%) had scheduled surveillance scans within 6 wk–65% were unwilling to delay scans. Among patients with metastatic disease, 76% were receiving active therapy. While most patients preferred not to defer therapy (51%), patients receiving immune therapy regimens were less amenable to deferring therapy than those receiving targeted treatment (20% vs 47%).

Conclusions

Despite high levels of anxiety surrounding COVID-19, many patients with RCC were inclined to adhere to existing schedules of surveillance (localized disease) and systemic treatment (metastatic disease).

Patient summary

The coronavirus disease 2019 (COVID-19) pandemic has prompted many doctors to develop different treatment strategies for cancer and other chronic conditions. Given the importance of the patient voice in these strategies, we conducted a survey of patients with kidney cancer to determine their treatment preferences. Our survey highlighted that most patients prefer to continue their current strategies of kidney cancer treatment and monitoring.

Patient-reported use of marijuana and cannabinoid (CBD) oil in patients with renal cell carcinoma undergoing systemic therapy

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Background: The use of cannabis and cannabinoid related products has become increasingly common among cancer patients. We sought to gather independent data from online kidney cancer patient communities to assess frequency of use of marijuana and CBD-oil and estimate influence on treatment duration and side-effects. Methods: The KCCure online survey was performed between August 1, and September 30, 2019. Descriptive statistics were used to characterize patients who self-report using marijuana, their systemic treatments, and interactions with their oncologists. Results: Out of 1,136 patients responding, 411 patients were on systemic therapy with a median age of 57 years (28-86). Of the 441 patients with systemic therapy, 223 patients (54%) were male. There was no difference in gender distribution or race among patients who reported using or not using marijuana and or CBD oil. 93 patients (21%) reported using marijuana or CBD oil and 35 patients (8.5%) reported using both. Patients using marijuana and/or CBD oil had a median age of 55.7 +/- 1.1 years compared with patients not using (65.1 +/- 6.9 years). The median treatment duration was 23.9+/-2.4 months for patients using marijuana and/or CBD oil versus 26.4+/- 1.9 months for patients not using these supplements (p=0.437). Patients using marijuana and/or CBD oil were more likely to have bothersome side effects from therapy (p=0.001) and were less likely to talk to their doctor about their situation (p=0.044). The median NCCN distress score in patients using marijuana and/or CBD oil was 49.5+/-25.7 versus 51.4+/-24.0 (p n.s.). No correlation was seen with the use of steroids, anti-diarrhea drugs, anti-nausea-drugs, hormone substitution or other drugs used to manage side effects. Conclusions: Marijuana and/or CBD oil are used by a significant number of patients. No benefit/harm on treatment duration and use of concomitant drugs to control side effects and severity was seen. Patients using marijuana and/or CBD oil were more likely to report bothersome treatment related side effects and were more willing to report their side effects to their provider. As cannabinoids become more mainstream and legal in a number of states, more research is needed to better understand the impact these supplements may have on patients.

Patient preferences and expectations of systemic therapy in renal cell carcinoma

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Background: In metastatic renal cell carcinoma, the systemic therapy landscape has expanded to include multiple VEGF inhibitors, immunotherapies, and combination therapy. Little is known about patient expectations and preferences when making decisions about systemic therapy. We sought to gather independent data from online kidney cancer patient communities to assess patient perspectives on what matters most when considering treatment options. Methods: The KCCure online survey was performed between August 1, and September 30, 2019. Patients were recruited via the KCCure website, social media channels (Twitter, Facebook) and through fliers distributed at cancer centers. Those who agreed to participate were surveyed for demographics (age, gender, race, income, country) and clinical characteristics (date of the diagnosis, disease stage, treatment history). Key questions focused on treatment selection and side effect management. Results: Out of 1,136 patients responding, 411 patients were on systemic therapy with a median age of 57 years (range 28-86). 223 (54%) of patients on systemic therapy were male. Patients were primarily from the U.S. (83%). Median duration on therapy was 24.7+/- 1.9 months. When asked to select the most important outcome for treatment selection, 58.8 % of patients chose complete response, followed by tumor control (10.2%), low risk of toxicity (5.7%) and the chance to discontinue therapy (3.7%). Patients ranked cost as the least important factor in selecting treatment (2.9%). 10.9% preferred infusion therapy and 42.1% oral therapy, whereas 47% were indifferent about the route of administration. Even if it would be safe to discontinue therapy, 62.8% of patients would be anxious about cancer progression. 23.2% would rather stay on treatment and 39.3% would want increased scanning intervals. Only 34.4% of patients would look forward to having more time off therapy. When asked to define treatment success, 86.3% selected reduction in tumor size, followed by stable disease (71.7%), freedom from symptoms (35.1%) and better quality of life (47.7%). Conclusions: Patients rank efficacy as the most important outcome when considering treatment options. Toxicity, time off therapy and cost are not significant priorities for patients. Further data is warranted investigating the impact of communicating treatment options, potential discontinuation of therapy and resulting expectations.

Fear of cancer recurrence among patients and survivors diagnosed with localized renal cell carcinoma

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Background: Fear of cancer recurrence (FCR) is considered one of the most pervasive and burdensome sources of distress for patients. Whereas it can be considered an adaptive response to real threats associated with diagnosis, treatment and disease, numerous studies have suggested that elevated levels can be dysfunctional. Despite this extensive body of research, little is known regarding FCR among individuals diagnosed with renal cell carcinoma (RCC). The current study sought to describe the prevalence of FCR among patients with RCC. Methods: Patients with localized RCC participated in an international survey from 07/19 to 09/19, through an online platform devised by a non-profit patient advocacy group (KCCure). Patients were assessed for FCR using the FCR-7, a 7-item measure, ranging from 0 to 28. A cutoff score of 17 indicates a moderate level of FCR, while a cutoff of 27 indicates severe level of FCR. Linear regression was used to determine the association between FCR and patients’ characteristics. Results: A total of 1150 patients participated in this survey, of which 412 had localized disease and were assessed for FCR. The majority were female (79%), with a median age of 54 years old (range, 30-80), and well-educated (58%). Patients were predominantly from US (85%), Canada (4%) and Germany (2%) and lived in suburban (48%) or rural areas (32%). More than half of participants were diagnosed with disease stage I (56%) and the remainder were divided between stage II (19%) and III (24%). More than half of patients (55%) reported a moderate or severe level of FCR. Younger patients (p=0.001) and those of female gender (p=0.004) were more likely to report higher levels of FCR. Conclusions: To our knowledge, this is the first study to quantify the degree of FCR among patients and survivors diagnosed with localized RCC. Importantly, high rates of FCR were associated with female gender and younger age, possibly driven by the fact that women may be more open to disclosing emotional symptoms and younger patients are still to pass through many life milestones and thus fear may be more pronounced. Targeted assessment and interventions are needed to address this highly prevalent form of distress among those diagnosed with RCC.

Patient-reported outcomes on treatment-related side effects in renal cell carcinoma

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Background: Effective management of treatment related toxicities is crucial to maximizing patient outcomes and enhancing quality of life in renal cell carcinoma. Little is known about patient perception and reporting of side effects in a real world setting outside clinical trials. We sought to gather independent data from online patient communities to estimate gaps in communication and reporting. Methods: KCCure conducted an anonymous online survey from 07/19 to 09/19 using questions related to side-effect experience and management. Results: 1,136 patients (median age 57 years [range 28-86], 54% male) participated, 411 patients on systemic therapy were asked about side-effects. 47% of patients reported bothersome side effects impacting their daily lives. The most poorly managed side-effect was fatigue (25%), followed by taste alteration (15%) and loss of appetite (15%). Only 50% of patients are confident their medical oncologist will offer help for side effects, and 20% are worried that reporting side effects may result in dose reduction or treatment discontinuation. 6% of patients don’t talk about their side effects. Patients who identified as non-white (Hispanic, African American, Asian/Pacific Islander and Native American) were three times less likely to talk about side effects. 51% indicated the best advice on managing treatment related side effects was provided by their medical oncologist; 40% seek advice from online patient communities and 35% from advocacy organizations. Only 8% used manufacturer support websites. 13% had never had any concomitant medication prescribed to manage side effects. Major unreported side effects are sexual dysfunction, cognitive impairment and vision disturbances. Conclusions: The majority of patients experience treatment related side-effects on a regular basis, but underreporting may be significant due to a variety of factors, including fear of dose-reduction or discontinuation. Sexual side-effects are underreported. Future studies need to explore differences in reporting for minority populations as well as side effect experiences according to the class of agent prescribed, and the setting in which treatment occurs.

The society for immunotherapy of cancer consensus statement on immunotherapy for the treatment of advanced renal cell carcinoma (RCC)

The approval of immunotherapeutic agents and immunotherapy-based combination strategies in recent years has revolutionized the treatment of patients with advanced renal cell carcinoma (aRCC). Nivolumab, a programmed death 1 (PD-1) immune checkpoint inhibitor monoclonal antibody, was approved as monotherapy in 2015 for aRCC after treatment with a VEGF-targeting agent. In April 2018, the combination of nivolumab and ipilimumab, a CTLA-4 inhibitor, was approved for intermediate- and poor-risk, previously untreated patients with aRCC. Then, in 2019, combinations therapies consisting of pembrolizumab (anti-PD-1) or avelumab (anti-PD-ligand (L) 1) with axitinib (a VEGF receptor tyrosine kinase inhibitor) were also approved to treat aRCC and are likely to produce dramatic shifts in the therapeutic landscape. To address the rapid advances in immunotherapy options for patients with aRCC, the Society for Immunotherapy of Cancer (SITC) reconvened its Cancer Immunotherapy Guidelines (CIG) Renal Cell Carcinoma Subcommittee and tasked it with generating updated consensus recommendations for the treatment of patients with this disease.

Comparing clinician- and patient-rated performance status and association with psychosocial status in advanced genitourinary cancer

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Background: Assessing patient-reported outcomes (PROs) is a critical element of comprehensive cancer care. Performance status (PS) is a widely used clinical measure to assess patients’ general well-being and, in clinical trials, provide insight into patients’ quality of life (QOL). This study compared PS as reported by clinicians and by patients, and explored whether associations between PS, QOL and psychological symptoms differed by patient or provider. Methods: This cross-sectional survey study enrolled patients with metastatic genitourinary cancers at a single institution. Patients completed measures assessing their PS (self-reported version of the Eastern Cooperative Oncology Group, ECOG), QOL (FACT-G) and psychiatric symptoms (PROMIS-Anxiety and Depression). Clinical data, including ECOG PS by physician rating, was extracted from medical records. Multivariate analysis was used to determine the association between PFS, QOL and psychological symptoms. Results: A total of 83 patients were enrolled. Median age was 67 (range, 31-91), 74% were male and 74% were married. Patients were diagnosed with advanced renal cell carcinoma (RCC; 54%), urothelial cancer (UC; 23%), or prostate cancer (PC; 23%) and were predominantly receiving first (39%) or second line (25%) therapy. Physicians were more likely to classify patients as ECOG PS 0 as compared to patients themselves (90% versus 63%, P = 0.01). Worse ECOG PS by patient-report was significantly associated with poorer psychosocial outcomes, including increased anxiety and decreased social well-being (P = 0.001 for each). In contrast, there was no association between physician-reported PS and these outcomes. Conclusions: This is the first study comparing PS as reported by clinicians and patients. Physicians appeared to overestimate ECOG PS when compared to patient self-rating, and this may have a downstream impact on the accuracy of PS for other psychosocial outcomes. This has potential implications for clinical trials in which PS is used for eligibility/stratification. This phenomenon will be examined prospectively in an upcoming SWOG trial in advanced RCC.

Patient perspectives on cytoreductive nephrectomy after CARMENA

658

Background: Conducted over eight years, enrolling 450 patients at multiple centers in Europe, the CARMENA (Cancer du Rein Metastatique Nephrectomie et Antiangiongeniques) trial demonstrated that systemic therapy using sunitinib alone is not worse than cytoreductive nephrectomy (CN) plus sunitinib in metastatic RCC in an intention to treat analysis (hazard ratio HR): 0.89, 95% confidence interval (CI), 0.71-1.10) (Mejean, NEJM, 2018). We wanted to assess patient views related to CN following the publication of these results. Methods: The Kidney Cancer Research Alliance (KCCure) conducted a survey among kidney cancer patients. The short survey was created via SurveyMonkey and was disseminated in various patient communities using social media and was posted to the KCCure website in June 2018 after the presentation of the CARMENA trial. Patients were asked “The CARMENA trial presented recently at ASCO found that for kidney cancer patients diagnosed with metastatic disease, there is no overall survival benefit of having a nephrectomy prior to starting systemic therapy. Knowing that information, would you still want to have a nephrectomy at diagnosis if you were metastatic?” Patients were also asked whether they had already had a nephrectomy and their stage at diagnosis, whether they were on systemic therapy, gender and age. Results: 186 patients responded with 60.5% being female. Median age 56.5 years (range 26-84). On the question of whether they would want CN. 75.2% of the patients indicated they would still prefer nephrectomy. Of the patients with primary metastatic disease and the tumor in place treated with systemic therapy, 20.1% wanted their kidney tumor to be removed. There was no statistically significant difference between patients who had experience with systemic therapy and those who hadn’t, answers were also consistent regardless of gender and age. Conclusions: Overall survival should not be overestimated as the most important aim in an end-stage patient population. Patients might think differently about benefits, risks and value of surgical procedures then physicians.

Sources of Frustration Among Patients Diagnosed With Renal Cell Carcinoma

Despite numerous therapeutic advances in renal cell carcinoma (RCC), little is known about patients' perspectives on cancer care. An international survey was conducted to identify points of frustration associated with cancer care reported by patients with RCC. Data were obtained from an online survey, conducted from April 1 to June 15, 2017, through social media and patient networking platforms. This survey obtained baseline demographic, clinicopathologic, and treatment-related information. Open-ended questions accessed sources of frustration in cancer-related care and patients' suggestions for amelioration. Responses were categorized and reviewed by independent reviewers. A qualitative analysis was performed and the Kruskal-Wallis test was used to define associations between baseline characteristics and sources of frustration. Among 450 patients surveyed, 71.5% reported sources of frustration, classified as either emotional (48.4%) or practical (23.1%). The most common were fear of recurrence/progression (15.8%), distrust of their cancer care system (12.9%), and lack of appropriate information (9.8%). Female gender and non-clear cell histology were associated with both types of frustration, and older age was linked to practical sources of frustration. Patients suggested solutions included greater compassion among health care practitioners (20.7%), better access to information (15.1%) and research to improve their chances of being cured (14.7%). Sources of frustration related to emotional and practical causes were identified amongst patients with RCC. Certain demographic and clinical characteristics were associated with more sources of frustration. This study provides the first characterization of specific ways to improve the patient experience by addressing common frustrations.

Frustration and distress during treatment for advanced renal cell carcinoma

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Background: Treatment strategies for advanced renal cell carcinoma (aRCC) have improved over the past 15 years. Durable responses are now achievable, giving rise to the possibility of cure in a small proportion of this population. However, it is not clear how patients are coping with more protracted courses of treatment. We sought to determine sources of frustration among patients diagnosed with aRCC. Methods: We performed a cross-sectional analysis of data derived from an online survey distributed via social media from April to June, 2017. We assessed source of frustration using an open-ended question: “In your own words, what has frustrated you most about your medical care related to your diagnosis?”. We assessed distress using the Distress Thermometer. Qualitative content analysis was performed to characterize responses related to frustration. Descriptive statistics was generated and the Kruskal-Wallis test was used to explore the relationship between clinical characteristics and sources of frustration. Results: We enrolled 217 patients with aRCC. The majority were male (52.3%), and white (93.5%). Clear cell histology (84.2%) was the most common diagnosis. Patients reported high levels of distress (M = 6.4; SD = 2.8). Sources of frustration were documented in 71.9% of patients, and were most commonly related to distrust of the cancer care system (12.4%), fear of progression (11.5%), lack of information (11.1%), financial concerns (9.7%), communication between patient and physician (7.8%), treatment side effects (4.6%), lack of available research (4.1%), mistrust of physician’s knowledge (4.1%), and access to supportive care (2.8%). Higher levels of frustration were associated with higher levels of distress (P = 0.01). Patients with non-clear cell RCC more commonly reported an emotional source of frustration (P = 0.02). Conclusions: Patients with aRCC report high levels of distress and frustration with their diagnosis and treatment. The most frequent drivers of frustration can suggest opportunities to maximize support to patients and their families. A better understanding of their disease and prognosis, addressing financial concerns and offering psychosocial support may alleviate frustration amongst patients with aRCC.

Development of a conversation aid tool for patients with localized renal cell carcinoma at high risk of recurrence

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Background: Approximately 15% of nephrectomised patients who are diagnosed with loco-regional renal cell carcinoma (RCC) are considered to be at high risk of recurrence according to the postoperative UCLA Integrated Staging System (UISS) and 60% of these patients are expected to recur within five years of diagnosis. This study aimed to develop a conversation aid tool to improve knowledge about RCC for post-nephrectomy RCC patients who are at high-risk of recurrence. Specifically, to enable patients to make an informed decision about whether to proceed/not proceed with adjuvant therapy, should adjuvant therapy become standard-of-care in the future. Methods: A review of existing evidence relating to the development of conversation aid tools and previously developed tools was undertaken. Following the review, a focus group with a steering committee (RCC patients, caregivers and a clinician), and semi-structured interviews were conducted with clinicians to identify information currently provided as standard of care. Additional interviews were conducted with post-nephrectomy patients, to identify information patients would prefer to have been given post-nephrectomy. Results: The evidence review of 10 articles provided a framework for the development of a tool to enable better patient/clinician communication. Clinicians described a typical post-nephrectomy consultation and highlighted key topics of discussion, which included recovery, risk of relapse and ongoing care. The research highlighted that patients are expected to absorb a significant amount of information during consultations in order to take an active role in their care. Findings from the focus group and clinician/patient interviews led to the development of a conversation aid tool providing patients with key questions to ask their clinicians to increase knowledge of RCC post-nephrectomy and also the information they may require when considering adjuvant therapy, including: prognosis, risk of relapse, and the risk/benefit profile of available treatment options. Conclusions: The conversation aid tool may be useful for patients to improve knowledge of RCC and help make informed decisions about their future treatment and care.

Patients perspectives on adjuvant therapy in renal cell carcinoma

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Background: At this point in time, there is no approved adjuvant therapy (AT) for renal cell carcinoma (RCC) . The discussion on AT is driven by the pending maturation of overall survival (OS) data for sunitinib in patients at high risk for recurrence. Data on patient´s perception of AT are missing. The purpose of this study was to assess the value of specific adjuvant outcome measures to patients with RCC. Methods: We conducted a survey-monkey survey in n=450 patients with RCC on the perspective on AT. The survey was promoted via kccure.org, facebook and smartpatients.com. Question were not related to specific results of adjuvant trials but asking only about the attitude towards AT as an intervention. Results: Median age was 55.6 years (17-82 years) and 56.4% of the patients were female. 73.6% of the patients underwent nephrectomy as primary therapy, while 22.0% had a partial nephrectomy. 76.4% of the patients had clear cell RCC. 39.1% had recurrence of RCC and 35.3% were receiving systemic therapy for metastatic RCC. 63.1% of patients would use AT if it prolonged OS, followed by 60.1% if AT prolonged disease free survival (DFS), 42.7% if AT demonstrated acceptable toxicity, and 36.7% if guaranteed insurance coverage and efficacy. Experience with systemic therapy was correlated with a wish for a prolonged OS (p<0.0001). Patients with a history of systemic therapy rely on the physician’s recommendation in contrast to patients without a history of systemic therapy (p<0.0001). The recurrence status, age, initial stage and type of surgery had no influence on the patients´ decisions. 28.0% of the patients would need more information prior to their decision, 24.2% would only take AT with a proven OS benefit, 16.9% would use AT if there was moderate toxicity, 13.6% would use AT independent of the associated toxicity level, 8.2% would only use AT without any toxicity. 3.8% of the patients would not use AT. Patients on systemic therapy had a significant higher acceptance of toxicity (p<0.0001). Conclusions: Patients are willing to use AT to achieve OS and DFS benefits, and place lower emphasis on toxicity. These data provide an important perspective on patient perceptions of AT, and emphasize the need for patient education on harms and benefits of AT.

Educating speech-language pathologists for a multicultural world

This paper presents critical elements and current needs in educating speech-language pathologists for a multicultural world. A proposed paradigm shift in clinical teaching using the UK model is also introduced. In addition, a case study on the American Speech Language Hearing Association's efforts in implementing the Multicultural Action Agenda by networking with the Asian Pacific Islander caucus is described. A survey of multicultural elements in programs in Australia and New Zealand is included. Finally, suggestions for collaboration with those in established professional bodies to meet the increasing needs of a multicultural world are provided.