Multidisciplinary management of clear-cell renal cell carcinoma in Africa and the Middle East: current practice and recommendations for improvement

Figures & data

Table 1 First-line treatment for RCC: Phase III trials

Treatment	Number	Prognostic group (%) G/I/P	ORR (%)	Median PFS (months)	Median OS (months)
Sunitinib vs	375/375	38/56/6	47 vs 12	11 vs 5	26.4 vs 21.8
IFN-α^Citation26,Citation27		34/59/7	P<0.001	P<0.001	P=0.051
Bevacizumab +	327/322	27/56/9	31 vs 13	10.4 vs 5.5	23.3 vs 21.3
IFN-α vs IFN-α^Citation30,Citation31		29/56/8	P=0.0001	P<0.001	NS
Bevacizumab +	369/363	26/64/10	25.5 vs 13.1	8.4 vs 4.9	18.3 vs 17.4
IFN-α vs IFN-α^Citation28,Citation29		26/64/10	P<0.0001	P<0.001	NS
Pazopanib vs	155/78	39/55/3a	32 vs 4	11.1 vs 2.8	22.9 vs 20.5
placebo^Citation32,Citation33		39/53/3a		P<0.0001	NSa
Sunitinib vs	553/557	27/59/9	25 vs 31	9.5 vs 8.4	29.1 vs 28.3
pazopanib^Citation34,Citation35		27/58/12	P=0.03	Non-inferior	NS
Temsirolimus vs	209/207	–/31/69	8.6 vs 4.8	5.5 vs 3.1	10.9 vs 7.3
IFN-α^Citation42		–/24/76	NS	P<0.001	P=0.008

Note:

a Total population.

Abbreviations: G, good; I, intermediate; IFN-α, interferon-alpha; NS, not significant; ORR, overall response rate; OS, overall survival; P, poor; PFS, progression-free survival; RCC, renal cell carcinoma; vs, versus.

Figure 1 PFS in patients randomized to second-line treatment with axitinib or sorafenib. Reprinted from The Lancet Vol 378, Rini BI, Escudier B, Tomczak P, et al. Comparative effectiveness of axitinib versus sorafenib in advanced renal cell carcinoma (AXIS): a randomised phase 3 trial; 1931–1939, Copyright 2011, with permission from Elsevier.

Abbreviations: PFS, progression-free survival; CI, confidence interval; HR, hazard ratio.

Table 2 Barriers to multidisciplinary review and interdisciplinary referral

Barriers to effective multidisciplinary cooperation	Poor communication Lack of awareness of the importance of multidisciplinary cooperation Time constraints and work load Limited availability of relevant specialists Logistical/organizational challenges(especially in private practice) Financial constraints
Specific barriers to referral from urologist/surgeon to oncologist	Lack of follow-up of patients after surgery Loss of patients to follow-up Patients’ social conditions Shortage of oncologists Costs of medication
Specific barriers to referral of medically treated patients for surgery	Poor communication Lack of awareness of benefits of cytoreductive nephrectomy and metastasectomy Shortage of urologists/surgeons Lack of continuity in the multidisciplinary team

Table 3 Multidisciplinary approach in Saudi Arabia: implementing good practice

Experience in Saudi Arabia in implementing a multidisciplinary approach provides a valuable model for consideration and wider adoption. In major Saudi tertiary hospitals, a tumor board, consisting of urologists or uro-oncologists, genitourinary medical oncologists, radiation oncologists, a genitourinary pathologist, and an interventional radiologist, regularly meets to discuss all new and ongoing genitourinary cancer cases. All cases are documented and the agreed management plan signed. In some centers, the uro-oncologist, genitourinary medical oncologist, and radiation oncologist see patients in specialist multidisciplinary out-patient clinics in adjacent rooms to facilitate cooperation. Regular monthly city-wide meetings are held to provide a forum for discussion of difficult cases and management dilemmas as well as for providing an opportunity to share knowledge and experience.

There is also a nation-wide Saudi uro-oncology group, including all uro-oncologists, genitourinary medical oncologists, and radiation oncologists. This group organizes regular multidisciplinary meetings and educational activities, develops guidelines, and sponsors multidisciplinary research and has evolved into the National Uro-Oncology Society.

Educational activities in Saudi Arabia include an annual uro-oncology congress, an annual training course for senior residents, and an annual update course for practicing urologists and oncologists. The Saudi Genitourinary Cancers Guideline committee was formed in 2010 under the umbrella of the Saudi Oncology Society and the Saudi Urological Association and has published clinical management guidelines for RCC.^Citation5

Abbreviation: RCC, renal cell carcinoma.

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