Transcript:Daniel Heng, MD, MPH, FRCPC: Talking about inclusion criteria, most of the patients were good- or intermediate-risk patients in a lot of these clinical trials. So, Susanne, what’s your approach to choosing the therapy for good or intermediate-risk patients?

Susanne Osanto, MD, PhD: Like Paul very eloquently explained, I tend to wait until there’s clear progression, or having the clinical impression based on Memorial Sloan Kettering criteria, or just your gut feeling as a clinician looking at the patient, that this patient, that the course of disease is going to be quite fast. So, when the decision is made to treat patients, I think the aim of the treatment, of course, is not to cure.

We can still not cure patients, so the primary aim is to prolong life but not to the extent, of course, that the quality of the life is very poor. So there should be a balance between side effects of treatment and improvement of overall survival.

For intermediate- and favorable-risk patients, we tend to use the same group of TKIs. And for poor-prognostic patients, in the past we tend to make a distinction and use the temsirolimus, based on the ARCC study. In honesty, although it’s a very easy way to treating patients, it’s not very toxic it’s easy, but it’s an in-house patient treatment. More and more, we used to also treat those patients similar to the ones who have been classified as favorable or intermediate-risk group patients. So, in principle, all three risk group categories get the same treatment, which is first-line VEGFR inhibitors. We have done bevacizumab plus interferon. In honesty, I do think that it’s a shame that bevacizumab, alone, was not a control arm in the pivotal trial, because I’m personally convinced it’s the bevacizumab and not so much the combination with interferon.

But because the phase III trial was with the combination, I think that we should treat patients with the combination, and what we see worldwide and, in particular, in Holland, is that the combination is used very rarely. I think the only reason being that you have to administer bevacizumab once every two weeks, intravenously, and then, interferon, three weekly subcutaneously, there are different side effects. It’s just a little bit more cumbersome, and everybody likes to treat patients with just a prescription and oral compounds. That’s what’s being done.

In the past, we’ve been using interleukin-2 (IL-2). Personally, I have very good experience with IL-2. I liked it a lot, although it’s quite intensive. It’s really intensive toward patients, but I like to do it and I hardly slept because every five minutes I had to make adjustments because of hypertension, anuria, etcetera. But I still have patients who are cured with it, so I think it’s a very good form of treatment, but it requires a whole setting in an ICU ward. So we tend not to give it any longer and I think, in all of Holland, where I live and work, nobody is giving IL-2. But I think it still stands as a treatment that can induce a cure, but it has a lot of toxicity.

Daniel Heng, MD, MPH, FRCPC: I agree. So I think the use of IL-2 and interferon are declining, I think and I agree that bevacizumab and interferon aren’t as commonly used because of the (toxicity of) combination.

Transcript Edited for Clarity