Editorial Comment on: Update on the Medical Treatment of Metastatic Renal Cell Carcinoma

Advanced and metastatic renal cell cancer (RCC) is resistant to conventional chemotherapy, and long-term survival with immunotherapy is rare. Since the advent of the ‘‘smart drugs,’ ’ however, the treatment of advanced RCC has made progress [1]. In this paper, the authors give substantial attention to ‘‘major improvements,’ ’ ‘‘major break-throughs,’ ’ and ‘‘especially promising data’’[2]. The results obtained have indeed been considered ‘‘exciting’ ’ by medical oncologists. However, uro-logical oncologists, who in Europe see most patients with RCC, are more cautious about the benefits of these new drugs on cancer-specific survival (increases in which amount to months and not years) and are more concerned about their initially underestimated toxicity. The authors extensively report on treatment regimens, often those that have been previously published; yet they deal with the toxicity of angiogenics and mTOR inhibitors in only a few sentences. Let us remember that a poor tolerance of the drugs can necessitate dose adaptation, which sometimes equals suboptimal regimens. Sometimes treatments must be stopped, exposing patients to possible disease exacerbation. New toxicities have been recently reported such as in intracerebral haemorrhage [3] and direct cardio-myocyte toxicity [4]. The latter certainly needs further exploration. Considering the efficacy and toxicity of these drugs, the statement made by the authors that ‘‘all other patients should be proposed anti-angiogenics’ ’ is perhaps a bridge too far [5]. The interesting points of the paper are the sequential and combination strategies (with una-voidable increased toxicity). Disappointing in our knowledge is the lack of predictive factors of response. Further research is needed [6] and we have to reassess the prognostic systems that were designed in the era of immunotherapy. Despite the results obtained with the small molecules, vaccination therapy is promising and needs to be further explored. Advanced RCC remains a challenge for organ-based specialists, but at least we have now medical treatments that we can discuss with our patients