Determining Front-Line Therapeutic Strategy for Metastatic Clear Cell Renal Cell Carcinoma

SIMPLE SUMMARY: Kidney cancer occurs more commonly within the general population and has historically been associated with morbidity and early death. The most common form of kidney cancer is clear cell renal cell carcinoma. Thankfully, there now have multiple new therapies available for patients with metastatic disease that are improving the lives of patients. However, the number of new drugs and treatment types has created a degree of complexity in treatment planning. We review the most recent data in the metastatic disease space surrounding treatment for patients with newly diagnosed metastatic clear cell renal cell carcinoma. These treatments include surgery, radiation, and systemic therapies. Current systemic therapies include drugs that activate the immune system to target cancer cells and small-molecule drugs that target a cancer cell’s ability to grow and survive. ABSTRACT: The therapeutic landscape for metastatic renal cell carcinoma has rapidly evolved over the years, and we are now in an era of combination therapy strategies employing immune checkpoint blockade and anti-angiogenesis targeted therapy. Since 2018, we have gained regulatory approval for four distinct combination therapies, all with survival benefits, and with guideline recommendation for use in the front-line setting. As such, treatment selection has become increasingly complex with a myriad of treatment choices but little high-level head-to-head data to guide treatment selection. Heterogeneity in tumor biology further complicates treatment selection as tumors vary in behavior and treatment responsiveness. Ongoing development of biomarkers will certainly assist in this setting, and validation of predictive markers represents an unmet need. In their absence, we highlight features of disease and nuances to datasets from landmark prospective clinical trials to help inform treatment selection. There is growing evidence to support deferring upfront systemic therapy in some patients, with opportunities for active surveillance or metastasis-directed therapy. In others, upfront systemic therapy is warranted and necessitates thoughtful consideration of multiple clinicopathologic parameters to inform optimal patient-centered decision making.