Adjuvant Therapy in Kidney Cancer: Patient Selection and Evolving Strategies

At the 2025 American Society of Clinical Oncology Genitourinary Cancers Symposium, a panel of experts discussed the latest research, emerging therapies, and best practices for treating renal cell carcinoma (RCC). Moderator Dr. Katy Beckermann of Tennessee Oncology was joined by Drs. David Braun, Matt Campbell, Brad McGregor, and Katie S. Murray in the discussion.

In the first segment of their conversation, the panelists explore the evolving role of adjuvant therapy in kidney cancer, highlighting patient selection criteria, the timing of therapy, and how medical oncologists and urologists can collaborate to optimize treatment strategies. The discussion also addresses the challenges of predicting recurrence risk and balancing the benefits and toxicities of adjuvant therapy.

View the next segment on The Future of Adjuvant Treatment for RCC: Biomarkers, Trial Data, and Clinical Challenges.

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Dr. Beckermann: Welcome everyone to this round table discussion. We’re here at ASCO GU 2025. My name is Katie Beckermann. I’m the medical director of GU Clinical Research at Tennessee Oncology and thrilled to be joined by colleagues today. I’ll let everybody go around the room. David, and let you start and introduce yourself.

Dr. Braun: Sure. I’m David Braun. I’m at Yale Cancer Center, a medical oncologist focused on kidney cancer and a lab investigator at the center of Molecular and Cellular Oncology.

Dr. Campbell: My name is Matt Campbell. I’m a genitourinary medical oncologist at MD Anderson Houston, Texas. Do a lot of research in kidney cancer with a specific interest in bone metastasis.

Dr. McGregor: And I’m Brad McGregor. I’m medical oncologist at Dana-Farber Cancer Institute where I’m a clinical trialist looking at novel clinical approaches and admin setting in a lot of the diverse histology.

Dr. Murray: I’m Katie Murray. I’m a urologic oncologist and I practice at NYU Langone in New York City.

Dr. Beckermann: Well, I’m thrilled to have you all here. I can’t wait for the discussion. So we’ll just make a logical discussion point and start with adjuvant and we’ll work our way through the treatment landscape. So Katie, maybe I’ll start by throwing it to you first, and I think one of the big questions that we all have is to hear your perspective on how do you approach the discussion about adjuvant treatment for patients with kidney cancer? Do you do it prior to surgery? How do you feel like your referral pattern is? Tell us about that.

Dr. Murray: Yeah, I think it’s something that definitely has evolved over the past year or two years. I think, as we first started with adjuvant therapies, it definitely was not part of an early conversation. A renal mass shows up in your clinic and you’re really just focused in on the surgery and then you say, we’ll see what the pathology shows and we’ll go from there. But I think when you see those masses that are larger that are going to be those high-risk population, I think with now, adjuvant therapy, it does force us a little bit instead of just saying, oh, you’re going to have surgery, this is one and done.

It would be our traditional way, I think as a urologist of what we would say. But kind of preempt that conversation, not in a fearful way, but this is the first step. The next step may guide us into something else. And that’s something that we use with our medical oncology colleagues. And so it might be advantageous to some people to visit with medical oncology before surgery depending on what that timeframe looks like. But more often than not, patients go to surgery, we see what their final pathology is, we’ve maybe preempted the conversation and then you see them within two to three weeks post-op.

Dr. Beckermann: Yeah, and do you refer everyone over or how does that go?

Dr. Murray: Yeah. So everybody who has T2 or greater disease has kind of been our across the board and then at least let that conversation happen. And I think from a urology perspective, we have often owned this and really been following the surveillance of these patients. And it’s nice to have medical oncology colleagues doing that with us at the same time, even for those patients who decide not to go on to adjuvant therapy. I don’t know if you guys have experienced the same thing with your urologist in your practices.

Dr. Beckermann: Yeah.

Dr. Braun: Yeah, absolutely. I think, especially, for those lower risk but still meets the Keynote 564 criteria, we have those conversations and sometimes the decision is not to do adjuvant therapy, but it’s still nice to sort of co-follow those patients.

Dr. Murray: Sure.

Dr. Beckermann: So do you all, when you’re meeting that patient to have the discussion about adjuvant treatment, maybe, have each of you go around and say how you approach it on an individual patient. Is there certain data that you think about or nomograms that you look at when you’re having that conversation? David, maybe I’ll let you start.

Dr. Braun: Yeah, absolutely. I sort of acknowledge that we’re not phenomenal at predicting risk of recurrence and there’s lots of tools and, frankly, none of them really agree with each other. I tend to use the assure nomogram as one that I think is a nice sort of modern one, but acknowledging again, those are rough numbers and really there’s limitations there. But I think it’s helpful because it gives a rough sense of the absolute risk. And so in my mind when I think about it, I think of where’s the absolute risk of recurrence. I think of what adjuvant pembro might do, hazard ratio, you know, whatever it is, 0.72 for disease-free survival. And so that helps me to frame it and talk to patients about what that might mean if they have one in three chance of coming back, maybe it’ll go down to a one in five at best-case scenario and how to balance that against the risk of toxicities, including, I’ve had patients who’ve had those lifelong toxicities like adrenal insufficiency.

And so those are the conversations we have. And for some patients they have really high-risk disease and we talk about it and the decision is pretty clear, but there’s some patients with, they have T3, they have no vascular invasion of perinephric fat, it’s grade two. Those are the ones that are a bit more subtle.

Dr. Beckermann: Yeah. Yeah. Matt, is that similar approach to what-

Dr. Campbell: Yeah. So it is fascinating because I think as the approval came, we had most of the trials open and Jose Karam and our urology group had led those trials with us at MD Anderson. And we put a lot of the patients on the trial. And we had kind of generated a workflow, but the number of referrals that we had coming in to discuss adjuvant therapy were massive, and it actually became harder to get our metastatic patients in the door. And so we, actually, formed kind of a working group around this to have more of a script on the urology side. And what we broke down was really the pros of giving adjuvant therapy. And we feel very strongly that Pembrolizumab does provide disease-free survival and that would likely be replicated. There was, I think, a very nice editorial written by Pavlos Msaouel and Dan Shapiro that highlighted the fact that the event rate was higher, as compared to the other adjuvant trials, which were not positive.

The risk grouping was probably tilted a little bit more to higher risk, more events. And that likely led to the signal that we saw there, as compared to the other three trials. But the overall survival benefit which was seen is likely going to be a challenge to replicate. And I don’t know if it would be replicated in the United States if it was a pure United States trial where you could guarantee IO experience in the metastatic setting.

And so we have a script where we talk about the pros, which is that we think we clearly can delay cancer recurrence. This does have potential life-threatening and life-altering toxicities, and this also may impact metastatic therapy, should patients relapse. And a lot of patients at our center will opt out of adjuvant therapy but will undergo careful surveillance. And if patients feel strongly about receiving because they’re very nervous about going on a surveillance program, we’re more than happy to offer. But it’s a very detailed conversation.

Dr. Murray: Can I ask you a question? So do you think the people that really opt out, and just getting a sense from the patients, is it the toxicity discussion or the discussion that if something happens down the road, what therapies are we going to lean on at that point in time? And you may not be able to answer that, but what is your sense for what fears the patient the most?

Dr. Campbell: I think it’s a little of both. I think the toxicity profile and I think single-agent IO therapy is very well-tolerated in, like, if we’re putting in the context of metastatic disease and the drugs that we use, the grade three and higher event rates is low, but we cause a lot of long-standing thyroid issues. We cause a lot of skin rash. We cause a lot of arthralgias and arthritis and then we, occasionally, get those lightning strikes. And so I quote patients, despite not having death in some of these studies, I mean, I think, historically, single-agent PD1 will give you around a one in 200 risk of death and that’s not something we can take away. And if you have a patient that’s never going to relapse, we know even with four years of follow-up, over half of patients on the KEYNOTE 564 have not relapsed. That is risk.

And so it’s really that factor. But then also we discussed that it does appear, if you’re exposed to a single-agent PD1 that does have an impact on your response in the metastatic setting. And so my fear is that the patients that are highest risk of relapse were probably under treating and these would be the sarcomatoid patients and these would be, potentially, some of the M-one type of patients. But I think that we are also overtreating a good number. And my hope is we continually refine this discussion. We have better biomarkers to help guide this discussion. We can really decide how we need to escalate and how we need to, potentially, avoid treating patients that clearly are not going to benefit from that approach.