RCC in the COVID Era: Early-Stage Operable Cancer
Interview recorded on March 31, 2020.
Dr. Moon: What are you guys considering high-risk factors that will rush you onto surgery and if the OR availability becomes even slimmer in the past…in the next few weeks, do you have any thoughts or any strategies? I think, Sumeet, why don't you take this on from the urology side, in terms of how you're defining the people that you consider urgent versus those that can go into short-interval follow-up. And Monty, maybe you can talk about some kind of plan B for patients...if we really do not have ORs available.
Dr. Bhanvadia: I would say at this point, anything less than 4 or 5 cm, we really are looking at postponement of that case for now. On the other hand, as you said, we feel like more a clinical T2, T3 mass, there is a window of opportunity that we certainly don't want to miss, and the added challenge for all of us in this moment is that we don't know how long these restrictions in terms of OR availabilities are going to go on for. So given that, if it’s a large mass, particularly one with perhaps some limited locoregional disease, some hilar nodes, or a renal vein thrombus, a small cable thrombus, we certainly are considering those as urgent surgeries and trying to get those done expeditiously.
On the other hand, for the more advanced thrombus cases, of course, these are rare, but when those come…when those do come up, we continue to discuss those at our multidisciplinary tumor board weekly, and we are, I think even to a greater extent, considering whether those patients can be stabilized and maintained with systemic therapy for now versus proceeding to surgery with what we know could be an extensive period of morbidity in the hospital, extensive use of ICU postoperatively, and higher risk to the patient and the surgical team.
Dr. Moon: Monty, what are your thoughts about…I will call it therapeutic window enlargement or prolongation schemes that you may have or we may have in medical oncology?
Dr. Pal: Yeah, I have to tell you, everything that Sumeet said is spot on. You know, I think that perhaps postponing those small renal mass cases makes a lot of sense for those cases that are perhaps those that would classically go to the operating room, the T2s and T3s. There’s good rationale to simply proceed, particularly because of that slippery slope that Sumeet had mentioned, if we start postponing cases, who knows what that OR backlog is going to look like in a couple of months? So we may really miss that window of opportunity that Sumeet alluded to. And finally, I would just reiterate what she said about those challenging cases. We have a patient who’s being put up at tumor board where there’s a question as to whether or not their level III of free thrombus is resectable. That patient will likely come into my clinic and receive systemic therapy up front and will contend with that surgical issue at a later time point. You know, frankly, that strategy of management is really quite similar both pre- and post-COVID. We might be a little less prone to consider those heroic efforts given that our systemic therapies are getting better and better.
Dr. Moon: So, I will speak a little bit from the community perspective, what we talked about in terms of strategies to lengthen that window. I know, Monty, I think, hands down combination IO therapy or even VEGF plus IO therapy has the best response rate. I think that data is irrefutable. I will tell you that from the Kaiser perspective, the recommendation I had made in terms of lengthening that window have been an oral TKI...number one, for the ease of use, and for the fact that about that 40% which you can stabilize, hopefully not forever, like looking for that few months before we can get [to] that OR backlog, so I wanted to bring that perspective because we are, as you mentioned, a community hospital, so the ER’s down the hall, COVID is next door. All of the patients now are funneled into one entrance, right, and so the exposure every time they come in is quite significant, so just the idea that…because I don't believe there’s an NCCN guideline, and that’s the debate that’s really kind of raging among all of us, which is the best way forward, and nobody really knows, so just a different perspective.
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