Patients receiving treatment for renal cell carcinoma (RCC) are often older and sicker than those included in pivotal trials, according to an analysis presented at the 2014 ASCO annual meeting. In the frontline setting for patients who present with paraneoplastic syndrome, data suggests that temsirolimus is superior to interferon, notes Janice P. Dutcher, MD. However, in many situations, poor prognostic factors are not evident until after treatment begins. For these patients, frontline treatment with a TKI could is still beneficial.

A review of the International MRCC Database Consortium revealed that the risk of death for patients in community setting is 1.55 times higher compared with patients in clinical trials, notes Daniel Heng, MD, MPH. For these patients, the decision between a TKI and temsirolimus should be based on patient characteristics, particularly administration route and tolerability.

In some situations, Heng notes, patients may present with brain metastases. For these patients, metastases should be treated using resection or stereotactic radiosurgery followed by standard treatment. Once brain metastases are controlled with localized treatment, progression-free and overall survival rates can be achieved that are similar to pivotal trials, Heng adds.