John Gore, MD, MS, Professor of Neurology at University of Washington, Attending Physician at Seattle Cancer Care Alliance and Affiliate Investigator at the Fred Hutchinson Cancer Research Center, talks about a new treatment for cancer patients.
Talk to me a little bit about kidney cancer. How common is it?
GORE: Kidney cancer is not one of the more commonly considered cancers in the U.S. It is one of the fastest growing cancers in terms of incidence along with thyroid cancer. We believe a lot of that relates to incidental detection. That’s because more people are getting CT scans for various indications, so we’re seeing more kidney tumors and thyroid tumors.
Are there any signs or symptoms that people can see beforehand?
GORE: The majority of patients are getting a CT scan for some other indication, like abdominal pain or back pain, and found to have a tumor in their kidney. But there are some symptoms that might indicate a kidney cancer is present. The sort of three that we think about the most would be a mass that you can feel or palpate in your abdomen or flank, a mass that maybe your doctor can feel or palpate with associated pain, and then blood in the urine.
What are some common treatments?
GORE: The most common treatment for kidney cancer is surgery. Basically, when a kidney cancer is confined to the kidney, depending on the stage, it is very curable. We think about treatments that balance taking out the cancer with leaving as much working kidney behind. Some surgery to remove part or all of the kidney is commonly prescribed for kidney cancer. There are other ways to kill the local kidney cancer using freezing technology or heating technology. That’s called a thermal ablation. Some patients with smaller tumors, we just watch. For more advanced cancers, cancer that has spread to other parts of the body, we think about what’s called systemic therapy or treatment for cancer cells throughout the body. That is typically with an IV infusion. For kidney cancer, we typically treat it with drugs that stimulate your immune system to fight the cancer.
Tell me a little bit about Brent. What led him to you and what was his prognosis?
GORE: When Brent came to us, he was someone who we suspected having metastatic kidney cancer. We try to coordinate so that those individuals see myself on the surgery side and they see one of our medical oncology providers, so we think about both treatments in parallel. Then what we try to figure out is if there is a role for removing their kidney as part of their overall cancer care. One unique aspect of kidney cancer is that even if the cancer has spread to other parts of the body, we oftentimes will remove the kidney. When Brent was diagnosed, we thought that that was part of improving their overall outcome and prognosis, so that’s what we prescribed for him. Then under the medical oncologist’s care, to give him treatment for cancer cells throughout the body.
How long was his recovery and how did that impact his daily life?
GORE: Brent underwent what I would call a major kidney removal surgery. It was an open surgery, which means that we usually are making an incision underneath the rib cage. That incision cuts through three muscle layers to try to get into the space where the kidney is. The recovery is usually around four days in the hospital. It’s a good while before people are really back on their feet and active. Brent was much younger than most patients when he was going through the surgery, which is both good and bad. It is good in that it’s good to be healthy and young when you’re going through major surgery. But it’s bad in that the expectation for what Brent wanted to get back to doing in life was a much more aggressive regimen than what most people undergoing this surgery are trying to get back to.
How long did it take him to get back to that?
GORE: I would say a couple of months. He will probably tell you a month. But probably a couple of months until he felt like a normal human being again.
With his treatment, or removing the kidney, were there any limitations to what he could do or could not do?
GORE: With respect to overall kidney health, not really. Brent is a hydroplane racer, which I imagine is an incredibly physically rigorous profession, and he returned to racing which is astounding. But in the immediate aftermath of surgery, he couldn’t do any strenuous physical activity or any heavy lifting for at least a month and preferably six weeks. We really recommend patients taking it easy for about a month to six weeks after that magnitude of complex surgery.
If he didn’t get treatment for his cancer, what could have happened?
GORE: With him having a suspicion for metastatic disease when he presented, if he had not embarked on the treatment that he had, his outcome would have been grim. Most patients with metastatic kidney cancer treated around the time that Brent was treated have a low likelihood of living until two years anyway given the therapies that were available at that time. And for him, if he had not been treated, the prognosis was probably that he would die within a year. We did what was called a laparoscopic radical nephrectomy. That’s a way of taking out the kidney instead of making our usual large morbid incision where we go through three muscle layers and impose upon people more of a prolonged recovery. This way, we can get away with smaller incisions, usually sort of the size of my pinky or the size of my thumb and use telescopic instruments to free up the kidney. Then we try to make a smaller incision that can usually be about the size of the width of my hand to take the kidney out. That’s what we were able to do for Brent.
How did that affect his recovery?
GORE: It definitely made his recovery shorter. Usually, if you have a big kidney surgery, you’re in the hospital for about four days. If you have a laparoscopic surgery, it’s either an overnight stay or a two-day stay in the hospital. Then the recovery at home is drastically shortened. For someone as active as Brent, usually by a month or six weeks out, he would still be recovering from a major open surgery. But with a laparoscopic operation by even two weeks, they’re usually off of pain medications and feeling sort of stronger and more active and more energetic. So for him, it was a big part of helping him return to his active life.
Were you able to figure out where the cancer spread?
GORE: When he showed up in our clinic, Brent had the main tumor in his kidney. But he also had some areas in the lungs that were strongly suspicious for areas where the cancer had spread. There was one sort of golf ball sized tumor in his lung that was highly suspicious and some scattered other areas in his lung that were also suspicious. That’s a classic clinical picture of metastatic kidney cancer.
After he had the surgery and then immunotherapy, did that help get rid of the spreading cancer?
GORE: He received a combination of two immunotherapies. In general, the role of immunotherapy is to rev up our immune system to fight the cancer. He got to what are called checkpoint inhibitors. So, our body constantly is performing this immune surveillance of the body, trying to clear our bodies of infections or small cancers, which are disordered cells that our body recognizes and detects and gets rid of. One of the ways in which our body outsmarts the cancer is it turns off the immune system’s ability to recognize it as something bad or abnormal. What the drugs Brent got do is turn back on the immune system so it can fight the cancer. That immune treatment completely eliminated the cancer deposits in his lungs.
So, he’s currently cancer free?
GORE: He is currently cancer free! He’s been off of cancer treatment now for about six months and just had a checkup with his medical oncologist and the x-rays were all clear.
What were the two drugs he received?
GORE: He received a combination of nivolumab and ipilimumab. Typically, when we prescribe those drugs, we give them as a combination for several cycles. After that more intensive period of treatment, they go forward just with the nivolumab, which is a little bit easier to tolerate. He was doing so well this past spring that Dr. Thompson had a discussion with him about stopping treatment altogether. So, he’s been off treatment.
What do you believe this has done to his quality of life?
GORE: It’s hard to argue that it’s dramatically increased his quality of life. By all metrics and objective data that we have available, it looks like he is currently cancer free. We never say that someone is cured. He’s going to continue getting close follow up through the Seattle Cancer Care Alliance. We’re now learning that many people who have what’s called a complete response, where all of the detectable deposits of cancer in their body appear to have shriveled up and disappeared, tends to be durable, meaning if you look at these patients five years or 10 years later, it appears that the response we saw maintains itself. So, I think there’s reason to be optimistic for Brent that this represents an incredible kind of change in his cancer outlook.
I know he coaches his son’s basketball team, so being able to do that again, I imagine is pretty incredible for him?
GORE: Yes. I think life is sort of as it was for Brent. He’s back racing, back doing his main chosen profession. He’s back engaging in a lot of the aspects of his personal life that you worry if not the cancer itself, but maybe the treatment that you got for cancer, is going to threaten. I couldn’t be happier for him that he’s able to do those things.
Is there anything else you feel people should know?
GORE: Well, just that kidney cancer is complex. For the majority of people who are diagnosed with suspicion for kidney cancer, where it looks like based on their scans and based on how they present that it’s confined to the kidney, those cancers are treatable and curable. A lot of them can just be watched conservatively. I think what happens when anyone hears the word cancer is a tremendous amount of anxiety, but it’s something that we can really help them navigate and move beyond. For patients with more advanced kidney cancer, that’s where something like multidisciplinary care, where bringing in as many big brains as you can get to think about how to give people the best outcome we can, is really important. We’re lucky at the Seattle Cancer Care Alliance that we have a kidney cancer multidisciplinary clinic. This is a single clinic where a patient can see in one sitting a urologist, a radiation oncologist, and a medical oncologist. We can all come together and figure out the best treatment plan for each patient. I think that’s really critical for those more advanced cancer patients.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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