How Would a Harvard Oncologist Manage His Own Metastatic Kidney Cancer?

When facing a frightening new cancer diagnosis, some people ask their doctors, “What would you do if you were me?” Here, our Curious Dr. George asks kidney cancer expert David J. Einstein, MD, how he would handle his own hypothetical case of kidney cancer. Dr. Einstein is Assistant Professor of Medicine in the Genitourinary Oncology Program at Harvard Medical School’s Beth Israel Deaconess Medical Center.

Curious Dr. George: Please consider this hypothetical scenario—you are an active clinical oncologist in general good health. But lately you have been feeling a little more tired than usual and have lost a bit of weight without dieting, so you decide to visit your primary care physician for a checkup. On physical examination, you are within normal limits, but a routine urinalysis demonstrates microscopic hematuria. A CT scan finds a rounded, 7-cm mass in the upper pole of your left kidney. On chest x-ray, one 2-cm rounded mass is found in the lower lobe of your right lung, and another similar mass is seen in the upper lobe of your left lung. How would you proceed?

David J. Einstein, MD: Before I dive into any of the oncology specifics, I would first acknowledge that this is a very difficult experience and that the most anxiety-provoking time of all is between hearing the diagnosis and learning of a treatment plan. I would definitely want to make sure that I have adequate social supports in place, understand my disability insurance and leave policies, and have access to a dedicated palliative care team to support me physically and emotionally as I embark on cancer-directed treatment.

The scenario outlined here is one of presumed metastatic disease, albeit without widespread metastases. We would first confirm that the pulmonary nodules are in fact metastatic kidney cancer with a biopsy, if feasible. We would then have a multidisciplinary evaluation. Assuming the pulmonary nodules are involved, I would think of this as “oligometastatic,” meaning a gray zone in between widely metastatic and localized.

I would start by assessing symptoms. In this case, it sounds like I have been feeling somewhat unwell, so I do need to start treatment. There are some situations in which we encounter de novo or recurrent metastatic kidney cancers that are asymptomatic and low-volume, and can sometimes be safely watched with close surveillance. We also do a clinical risk stratification. This is mostly for prognostic purposes, although there are some subtle distinctions regarding which systemic therapies are approved for which risk groups.

Then, I would be faced with the decision between systemic therapy first versus some combination of local and systemic therapy. In a situation of more widely metastatic disease, I would certainly opt for systemic therapy first, with some question of coming back to surgery later on, depending on my response and how much disease was within the kidney versus elsewhere.

In this situation, however, it may be reasonable to be aggressive with local therapies, assuming I am in good health. I would consider nephrectomy—removal of the kidney entirely—and some form of local therapy to the lung nodules, either surgery or radiation. By using all of these local therapies, we would be trying to render me disease-free, at least macroscopically. However, I would be concerned that microscopically, there could be some leftover cancer cells that could cause later recurrences. Therefore, I would consider receiving “adjuvant” immunotherapy with the goal of decreasing my risk of recurrence.

We have been using immunotherapies, especially immune checkpoint inhibitors, in metastatic kidney cancer for years. More recently, a study showed benefit for using one year of an immune checkpoint inhibitor, pembrolizumab, after surgery for patients with high-risk localized or oligometastatic kidney cancer, resulting in FDA approval. I would be receiving infusions of this every 3-6 weeks, depending on the dose, and monitoring closely for signs of excess immune activation against my own body, creating essentially an autoimmune condition. The fundamental goal here would be long-term remission, trying to be free of both cancer and treatment, for as long as possible.

Dr. Einstein can be reached at deinstei@bidmc.harvard.edu.

 

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