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The management of elderly metastatic Renal Cell Carcinoma (mRCC) patients

Background
Increased life expectancy has led to a significant expansion in the elderly population. By the year 2020, it is estimated that between one-fifth and one-quarter of the population in the Western world will be aged 65 years or more (Yancik R, Ries LA. Aging and cancer in America. Demographic and epidemiological perspectives. Hematol Oncol Clin North Am 2000; 14 (1): 17–23).

According to the National Cancer Institute, >60% of all incident cancers and 70% of all cancer-related deaths occur in patients >65 years of age and so there are a significant and rapidly increasing number of older patients who need appropriate cancer care (Ries L, Kosary C, Hankey B (eds). SEER Cancer Statistics Review, 1975–1995. Bethesda, MA: National Cancer Institute 1998)

Physiological changes associated with aging, such as declining renal function and decreasing reserve in multiple organ systems, predispose the elderly to cancer drug toxic effects.

Treatment of metastatic renal cell carcinoma (mRCC) has evolved tremendously over the past decade since the advent of targeted therapies. In line with this, SIOG had established a task force in 2008 to come up with treatment recommendations for the elderly mRCC patient, an important group that has often been overlooked in terms of recruitment into clinical trials1. In that guideline which was published in a high impact journal in 2009, the task force not only analyzed the evidence regarding the state of art management in mRCC in the elderly but was also able to apply that knowledge by taking into consideration factors unique to an elderly population. These factors include physiological, pathological, pharmacological, and psychological factors that distinguish the older mRCC patients from those younger1.

It’s been 6 years since the publication of the above position paper and the treatment landscape has changed a lot since. In the 2009 paper1, the data for targeted therapies for use in mRCC patients were limited to Sunitinib2, Sorafenib3, Temsirolimus4, Everolimus5 and Bevacizumab with Interferon6. However since then we have a number of other drugs that have come to the forefront in the treatment of mRCC; like Pazopanib7 and Axitinib8 and we have better clarity on how best to sequence these drugs as well. Quality of life improvement and patient preference studies9 related to it have made this drug a feasible option for the frail and elderly population. We also have more data now regarding how these drugs work in the elderly population too.

In July 2014, SIOG ( International Society of Geriatric Oncology) organized a major regional meeting covering the Asia Pacific region (SIOG APAC 2014) to highlight the issues afflicting older cancer patient in the most rapidly ageing part of the world. During this meeting, Dr Ravindran Kanesvaran, the host of the SIOG APAC meeting and genitourinary cancer oncologist from the National Cancer Centre Singapore had made a presentation on the “optimal management of metastatic renal cell carcinoma in the elderly”. It was then that the idea of updating the current guideline was conceived. It is hoped that the updated guideline that we are planning will further enhance the care of elderly mRCC patients with the advent of better therapy that have been developed over the past 6 years.

Aims
This task force will review the available evidence:

  1. To incorporate the latest therapies in the care of elderly mRCC in both the first and second line of treatment while taking into account principles of geriatric management
  2. To provide guidance on how to sequence treatment in elderly mRCC patients
  3. To assess both clinical trial and real world data on the use of state of the art therapies in older mRCC patients and incorporate them into our guideline

Task force experts

Chair/ co-chair:
Ravindran Kanesvaran (SNG)
V. Launay-Vacher (FR; C-KIN representative)

Writing Committee
Robert Motzer (USA)
Florian Scotté (FR) 
Toni Choueiri (USA)
Joaquim Bellmunt (SP)
Young SIOG representation: Olivia Le Saux (FR)

This project is supported by unrestricted grants from Novartis and Pfizer.