Evaluating novel monitoring techniques with circulating tumour DNA and updated quality of life surveys for patients with metastatic renal and urothelial cancers

Renal cell carcinoma (RCC) accounts for approximately 2% of all cancer types. (1) Metastatic RCC is generally incurable however with advancements in immunotherapy-based treatments, survival outcomes have been improving. For example, combination treatment with nivolumab ipilimumab in the CheckMate 214 trial has reported a median OS of over five years. (2) The number of therapies for RCC has expanded over the past decade. Immunotherapy agents such as PD1/L1 inhibitors are the current cornerstone of treatment, either in combination with CTLA4 inhibitors (nivolumab ipilimumab) or with various tyrosine kinase inhibitors (TKIs) including lenvatinib, axitinib, and cabozantinib (2-5). Treatment options do vary by jurisdiction and reimbursement is often dependent on the International Metastatic RCC Database Consortium (IMDC) risk stratification score; for example, in the United Kingdom, patients with metastatic RCC with a favourable risk score are limited to the single agent TKI sunitinib and are not eligible for combination treatment. All systemic therapies for metastatic RCC have notable side effects including but not limited to fatigue, poor appetite, diarrhoea, and rash. As such, to delay treatment related side effects, active surveillance is a widely used initial management strategy. This involves delaying systemic therapy and instead monitoring disease progression with intermittent CT scans, and only proceeding with systemic therapy after a notable amount of disease progression has occurred. This has been studied in a prospective phase II trial and is an accepted and safe management option for patients. (6)