It’s a curious predicament that we face these days in metastatic (stage IV) kidney cancer. Whereas a decade ago, the choice of therapy was obvious, these days, it’s a challenge to select the optimal first line agent.

Let me put this in perspective – when interleukin-2 (IL-2) was approved for metastatic kidney cancer back in 1992, there wasn’t much else to choose from. Treatments like interferon-alfa only worked to slow down the disease temporarily, and standard chemotherapy seemed to do little in the majority of patients. With this in mind, IL-2 seemed like a reasonable option. There are a couple of caveats, however. Theoretically, IL-2 works by stimulating the body’s immune response against cancer. To do this, it induces something akin to an incredibly severe flu – the patient’s blood pressure can drop substantially, and the patient can develop high fevers and infection. The net effect of these changes can be disastrous to heart and lung function. As such, IL-2 treatment was generally limited to folks who were otherwise in good health and perhaps a bit younger. There were also a couple of commonly held notions about IL-2 – for instance, it was thought that it might work best in patients with really limited disease, confined to the lungs, but not spread to the bones and other organs.

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