title: Treatment of patients with metastatic renal cell cancer: a RAND Appropriateness Panel.
abstract: BACKGROUND
  New developments in the treatment of patients with metastatic renal cell cancer (MRCC) have suggested a need to reevaluate the role of systemic therapies. The authors convened a panel of medical and urologic oncologists to rate the appropriateness of the main options.
  
  
  METHODS
  The authors used the RAND/University of California-Los Angeles Appropriateness Method to evaluate systemic therapy options and cytoreductive nephrectomy. After a comprehensive literature review, an expert panel rated the appropriateness of systemic options (108 permutations) and cytoreductive nephrectomy (24 permutations) for patients with MRCC.
  
  
  RESULTS
  The appropriateness evaluation indicated that 27.3% of permutations were rated "appropriate," 46.9% were rated "inappropriate," and 25.8% were rated "uncertain." There was a high rate of agreement (95%). Sunitinib and sorafenib were rated appropriate for patients with low-to-moderate risk regardless of prior treatment. Temsirolimus was rated appropriate for first-line therapy for higher risk patients. Interferon-alpha and low-dose interleukin-2 were rated inappropriate or uncertain. In patients who received prior immunotherapy, cytokines were rated inappropriate. In all permutations for evaluating systemic therapy, enrollment into an investigational trial was considered appropriate, treatment with bevacizumab was uncertain, and thalidomide was inappropriate regardless of risk status or prior therapy. For good surgical risk patients with planned immunotherapy, nephrectomy was rated appropriate in patients who had limited metastatic burden regardless of tumor-related symptoms and in symptomatic patients regardless of metastatic burden. Only the most favorable combination of surgical risk, metastatic burden, and symptoms generated an "appropriate" rating for patients with planned targeted therapy.
  
  
  CONCLUSIONS
  The current results begin the process of defining an appropriate role for cytokines, newer targeted therapies, and surgery in the treatment of MRCC.
authors.affiliation: Cerner Life Sciences, Beverley Hills, California, USA. halbert@ucla.edu
authors.forename: Ronald J
authors.initials: RJ
authors.lastname: Halbert
authors.forename: Robert A
authors.initials: RA
authors.lastname: Figlin
authors.forename: Michael B
authors.initials: MB
authors.lastname: Atkins
authors.forename: Myriam
authors.initials: M
authors.lastname: Bernal
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Hutson
authors.forename: Robert G
authors.initials: RG
authors.lastname: Uzzo
authors.forename: Ronald M
authors.initials: RM
authors.lastname: Bukowski
authors.forename: Khuda Dad
authors.initials: KD
authors.lastname: Khan
authors.forename: Christopher G
authors.initials: CG
authors.lastname: Wood
authors.forename: Robert W
authors.initials: RW
authors.lastname: Dubois
mesh_terms: D002292:Carcinoma, Renal Cell / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D002986:Clinical Trials as Topic; D016207:Cytokines / Q000627:therapeutic use; D019317:Evidence-Based Medicine; D006801:Humans; D007680:Kidney Neoplasms / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D009362:Neoplasm Metastasis / Q000628:therapy; D009392:Nephrectomy
chemical_list: D016207:Cytokines