Camillo, Porta

Laura, Cosmai

Pietro, Previtali

PORTA, CAMILLO GUGLIELMO GIUSEPPE

PREVITALI, PIETRO

COSMAI, LAURA

Archivio Istituzionale della Ricerca - Università degli Studi di Pavia

Immunotherapy has long been used in treating aRCC, withinterferons and interleukins commonly used in the past. It isalso expected that the patterns of care for aRCC will hold animportant role for the newer immunotherapy medications asthey become more popular. We have no doubt that the pro-grammed death-ligand 1 inhibitor drugs, nivolumab (Opdivo;Bristol-Myers Squibb Company, Princeton, NJ, USA) isalready approved for aRCC, will be more commonly used foraRCC.Mohamed H Kamel M.D., F.A.C.S.1 and Nabil K BissadaM.D., F.A.C.S.2,31Department of Urology, University of Arkansas for MedicalSciences, Little Rock, Arkansas, 2Department of Urology,Baylor College of Medicine, and 3Michael E. DeBakeyVeterans Affairs Medical Center in Houston, Houston, Texas,USAbissadan@hotmail.comDOI: 10.1111/iju.13335References1 Pal SK, Signorovitch JE, Li N et al. Patterns of care among patients receivingsequential targeted therapies for advanced renal cell carcinoma: a retrospectivechart review in the USA. Int. J. Urol. 2017; 24: 272–8.2 Kamel MH, Moore PC, Bissada NK, Heshmat SM. Potential years of life lostdue to urogenital cancer in the United States: trends from 1972 to 2006 basedon data from the SEER database. J. Urol. 2012; 187: 868–71.3 Schnipper LE, Davidson NE, Wollins DS et al. American Society of ClinicalOncology statement: a conceptual framework to assess the value of cancertreatment options. J. Clin. Oncol. 2015; 33: 2563–77.Editorial CommentEditorial Comment from Dr Porta et al. to Patterns of care among patients receivingsequential targeted therapies for advanced renal cell carcinoma: A retrospective chartreview in the USAIn this issue of the journal, Pal et al. reported on patterns ofcare among metastatic renal cell carcinoma in the USA.1At present, the metastatic renal cell carcinoma therapeuticlandscape in industrialized countries resembles, to a certainextent, the one shown therein: a growing number of meta-static renal cell carcinoma patients are receiving several linesof treatments sequentially, and this abundance of options hasundoubtedly improved their survival.However, this situation also encompasses some risks, irrespec-tive of the fact that unexpected disparities between countries inthe (once) rich and industrialized Western world are emerging.First, the availability of so many active agents could alsocontribute to non-virtuous behaviors.Indeed, if one can easily move from one agent to anotherin the event of toxicities, even only a few days after com-mencing the treatment, why try to adapt the treatment dosageand schedule, and/or aggressively apply supportive measuresin order to keep the treatment going?An unusual scenario, one might say. Not really; this isquite often observable in everyday clinical practice, althoughalmost no scientific papers have ever dealt with this issue.If so, it is clear that all the knowledge we have gatheredover the years might simply vanish at the first difficulty, orin the presence of a complaint (although often justified) fromthe patient.2On the whole, is this possibility an opportunity, or a pitfall?Both, but with a disturbing trend towards the latter case.Indeed, managing toxicities by just shifting from one agentto the other, just because the latter is perceived as (or even is)less toxic, not only deprives a given patient of an option(which, in many countries, cannot be resumed later), but alsopotentially has a detrimental impact on the treatment outcome.3Despite a fast approval system empowered by the Euro-pean Medicines Agency, a second emerging issue is the dis-parity among European countries in the real availability ofnovel anticancer agents.Several years ago, Tim Eisen strongly criticized the Britishsystem for denying the reimbursability of several kidney can-cer drugs due to economic considerations.4 Although difficultto accept from a patient’s perspective, such a decision wasbased on serious pharmacoeconomical and macroeconomicalconsiderations.What in recent years has happened in Italy is definitelymore difficult to understand; denying highly active treatmentsto cancer patients just because the Italian Agency for Drugs“fights” pharmaceutical companies over drug prices is reallyhard to accept.This is just an ultimately useless way to save money,without any serious attempt to prioritize expenses by evalu-ating how much expense is worthwhile for a given clinicalbenefit.That’s why the magnitude of clinical benefit scale recentlyempowered by the European Society of Oncology should beapplauded, offering governments sound instruments to decideif, how and where to allocate resources in a tough global eco-nomic situation.5However, the subsequent necessary step would (andshould) be the real application of such an instrument.The choice of not taking any responsibility, but rather topass these responsibilities on to those who produce andsell the drugs, thus denying patients (i.e. those whom agovernment regulatory body should serve) therapeuticopportunities and probably months of life, is not theanswer.© 2017 The Japanese Urological Association 279Renal cell carcinoma: Patterns of careFortunately enough, a medical oncologist now chairs theItalian Agency for Drugs, hopefully bringing patients (andnot drugs) back to center stage.Camillo Porta M.D.,1,4 Laura Cosmai M.D.2,4 and PietroPrevitali Ph.D.31Medical Oncology, I.R.C.C.S. San Matteo UniversityHospital Foundation, Pavia, 2Nephrology and Dialysis,Azienda Socio - Sanitaria Territoriale di Cremona, Cremona,3Department of Economics and Management Sciences,University of Pavia, and 4Italian Group of Nephro-Oncology(G.I.O.N.), Pavia, Italyc.porta@smatteo.pv.itDOI: 10.1111/iju.13351Conflict of interestCP acted as a consultant and/or speaker for Pfizer, Novartis,BMS, Ipsen, Eisai, EUSA, Peloton and Jannsen. LC and PPdeclare no conflict of interest.References1 Pal SK, Signorovitch JE, Li N et al. Patterns of care among patients receivingsequential targeted therapies for advanced renal cell carcinoma: a retrospectivechart review in the USA. Int. J. Urol. 2017; 24: 272–8.2 Porta C, Chiellino S. Long-term safety of targeted agents used to treat meta-static renal cell carcinoma: the issue is not the rate of adverse events overtime, but the expertise needed to manage them. Transl Cancer Res 2016; 5(S3): S613–5.3 Porta C, Levy A, Hawkins R et al. Impact of adverse events, treatment modifi-cations, and dose intensity on survival among patients with advanced renal cellcarcinoma treated with first-line sunitinib: a medical chart review across tencenters in five European countries. Cancer Med. 2014; 3: 1517–26.4 Eisen T. The National Institute of Health and Clinical Excellence rejects newtreatments for renal cell cancer: Cinderella’s invitation is cancelled. BJU Int.2008; 102: 1491–2.5 Cherny NI, Sullivan R, Dafni U et al. A standardised, generic, validatedapproach to stratify the magnitude of clinical benefit that can be anticipatedfrom anti-cancer therapies: the European Society for Medical OncologyMagnitude of Clinical Benefit Scale (ESMO-MCBS). Ann. Oncol. 2015; 26:1547–73.280 © 2017 The Japanese Urological AssociationSK PAL ET AL.

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Editorial Comment from Dr Porta et al. to Patterns of care among patients receiving sequential targeted therapies for advanced renal cell carcinoma: A retrospective chart review in the USA

Editorial Comment from Dr Porta et al. to Patterns of care among patients receiving sequential targeted therapies for advanced renal cell carcinoma: A retrospective chart review in the USA

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