Expert consensus on patterns of progression in kidney cancer after adjuvant immunotherapy and subsequent treatment strategies

Immunotherapy has changed the management of localized clear cell renal cell carcinoma (ccRCC) since the approval of adjuvant pembrolizumab, which demonstrated significant improvements in disease-free survival (DFS) and overall survival (OS) in patients at intermediate and high risk of recurrence. This new approach impacts rescue strategies in patients who relapse after local treatment and during or after adjuvant pembrolizumab. Nevertheless, there is currently no robust scientific evidence on therapeutic decision-making in this clinical situation, representing an area for further debate and research.

In this article, a group of experts from the Genitourinary Alliance for Research and Development (GUARD) have reviewed the available scientific evidence to establish the basis for therapeutic decision-making in patients with ccRCC who progress after adjuvant treatment with immunotherapy. Despite the lack of randomized clinical trials in this setting, this group of experts recommends classifying patients according to relapse volume (oligometastatic vs. polymetastatic), time to relapse and certain molecular characteristics. Rescue treatments beyond relapse should be individualized and might include locoregional treatments such as surgery or radiotherapy as well as antiangiogenic therapies in patients defined as resistant to immunotherapy.