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Renal cancer

About

What is covered

This interactive flowchart covers renal cancers.

Updates

Updates to this interactive flowchart

2 October 2018 Cabozantinib for untreated advanced renal cell carcinoma (NICE technology appraisal guidance 542) added to first-line treatment for advanced and metastatic renal cancer.
20 March 2018 Tivozanib for treating advanced renal cell carcinoma (NICE technology appraisal guidance 512) added to first-line treatment for advanced and metastatic renal cancer.
23 January 2018 Lenvatinib with everolimus for previously treated advanced renal cell carcinoma (NICE technology appraisal guidance 498) added to second-line treatment for advanced and metastatic renal cancer.
7 November 2017 Recommendations in second-line treatment for advanced and metastatic renal cancer amended after a change to the commercial arrangements for NICE's technology appraisal guidance on nivolumab for previously treated advanced renal cell carcinoma. The changes do not affect the cost effectiveness of nivolumab.
8 August 2017 Cabozantinib for previously treated advanced renal cell carcinoma (NICE technology appraisal guidance 463) added to second-line treatment for advanced and metastatic renal cancer.
21 February 2017 Everolimus for advanced renal cell carcinoma after previous treatment (NICE technology appraisal guidance 432) added to second-line treatment for advanced and metastatic renal cancer.
22 November 2016 Nivolumab for previously treated advanced renal cell carcinoma (NICE technology appraisal guidance 417) added to second-line treatment for advanced and metastatic renal cancer.
24 February 2015 Axitinib for treating advanced renal cell carcinoma after failure of prior systemic treatment (NICE technology appraisal guidance 333) added to second-line treatment for advanced and metastatic renal cancer.
31 October 2014 Single-port laparoscopic nephrectomy (NICE interventional procedures guidance 414) added to procedures for treating renal cancer.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on renal (kidney) cancer in an interactive flowchart

What is covered

This interactive flowchart covers renal cancers.

Updates

Updates to this interactive flowchart

2 October 2018 Cabozantinib for untreated advanced renal cell carcinoma (NICE technology appraisal guidance 542) added to first-line treatment for advanced and metastatic renal cancer.
20 March 2018 Tivozanib for treating advanced renal cell carcinoma (NICE technology appraisal guidance 512) added to first-line treatment for advanced and metastatic renal cancer.
23 January 2018 Lenvatinib with everolimus for previously treated advanced renal cell carcinoma (NICE technology appraisal guidance 498) added to second-line treatment for advanced and metastatic renal cancer.
7 November 2017 Recommendations in second-line treatment for advanced and metastatic renal cancer amended after a change to the commercial arrangements for NICE's technology appraisal guidance on nivolumab for previously treated advanced renal cell carcinoma. The changes do not affect the cost effectiveness of nivolumab.
8 August 2017 Cabozantinib for previously treated advanced renal cell carcinoma (NICE technology appraisal guidance 463) added to second-line treatment for advanced and metastatic renal cancer.
21 February 2017 Everolimus for advanced renal cell carcinoma after previous treatment (NICE technology appraisal guidance 432) added to second-line treatment for advanced and metastatic renal cancer.
22 November 2016 Nivolumab for previously treated advanced renal cell carcinoma (NICE technology appraisal guidance 417) added to second-line treatment for advanced and metastatic renal cancer.
24 February 2015 Axitinib for treating advanced renal cell carcinoma after failure of prior systemic treatment (NICE technology appraisal guidance 333) added to second-line treatment for advanced and metastatic renal cancer.
31 October 2014 Single-port laparoscopic nephrectomy (NICE interventional procedures guidance 414) added to procedures for treating renal cancer.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Improving outcomes in urological cancers (2002) NICE guideline CSG2
Cabozantinib for untreated advanced renal cell carcinoma (2018) NICE technology appraisal guidance 542
Tivozanib for treating advanced renal cell carcinoma (2018) NICE technology appraisal guidance 512
Cabozantinib for previously treated advanced renal cell carcinoma (2017) NICE technology appraisal guidance 463
Everolimus for advanced renal cell carcinoma after previous treatment (2017) NICE technology appraisal guidance 432
Nivolumab for previously treated advanced renal cell carcinoma (2016 updated 2017) NICE technology appraisal guidance 417
Pazopanib for the first-line treatment of advanced renal cell carcinoma (2011 updated 2013) NICE technology appraisal guidance 215
Irreversible electroporation for treating renal cancer (2013) NICE interventional procedures guidance 443
Single-port laparoscopic nephrectomy (2011) NICE interventional procedures guidance 414
Laparoscopic cryotherapy for renal cancer (2011) NICE interventional procedures guidance 405
Percutaneous cryotherapy for renal cancer (2011) NICE interventional procedures guidance 402
Percutaneous radiofrequency ablation for renal cancer (2010) NICE interventional procedures guidance 353
Laparoscopic partial nephrectomy (2006) NICE interventional procedures guidance 151
Laparoscopic nephrectomy (including nephroureterectomy) (2005) NICE interventional procedures guidance 136

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Lenvatinib with everolimus

In the NHS, advanced renal cell carcinoma that has progressed after 1 tyrosine kinase inhibitor is treated with axitinib, nivolumab or cabozantinib. The evidence from a single clinical trial suggests that, on average, people live around 10.1 months longer if they have lenvatinib plus everolimus rather than everolimus alone. In the trial, lenvatinib plus everolimus caused side effects, leading many patients to interrupt or even stop treatment. This is despite the patients enrolled in the trial being relatively fit (that is, they had an ECOG performance status score of 0 or 1).
The cost-effectiveness analyses for lenvatinib plus everolimus show it's more effective and less costly than cabozantinib and nivolumab. Compared with axitinib, the cost-effectiveness estimates are within what NICE normally considers acceptable. So, NICE is recommending lenvatinib plus everolimus as an option for use in the NHS in people with an ECOG performance status score of 0 or 1.
For more information see the committee discussion in the NICE technology appraisal guidance on lenvatinib with everolimus for previously treated advanced renal cell carcinoma.

Tivozanib

Current treatment in the NHS for untreated advanced renal cell carcinoma is usually sunitinib or pazopanib. There is no evidence to suggest that tivozanib is more effective than pazopanib and sunitinib in extending overall and progression-free survival. At best, tivozanib may have a similar effect to sunitinib or pazopanib. Also, the evidence does not clearly show that people tolerate the adverse effects of tivozanib better than those of sunitinib or pazopanib.
The cost of treating renal cell carcinoma with tivozanib is likely to be lower than the cost of treating it with sunitinib or pazopanib, but tivozanib is also likely to be less effective. The estimated cost savings are high enough to compensate for the estimated lower effectiveness. Also, there is a need to be able to offer tivozanib to people who do not tolerate existing treatments. Therefore, tivozanib is recommended as an option for treating advanced renal cell carcinoma in adults who have had no previous treatment.
For more information see the committee discussion in the NICE technology appraisal guidance on tivozanib for treating advanced renal cell carcinoma.

Rationale: cabozantinib

Current treatment for untreated advanced renal cell carcinoma is usually pazopanib or sunitinib.
Clinical trial evidence shows that cabozantinib extends the time until cancer progresses compared with current treatment. But the evidence on whether cabozantinib increases how long people live is less certain. It appears to be at least as effective as current treatment, but it's not clear how much extra benefit it offers.
Cost-effectiveness estimates for cabozantinib compared with current treatment are uncertain. This is because there is not much evidence available to estimate how long people live, and the costs and benefits of treatments after cabozantinib do not fully reflect those in the NHS. The cost effectiveness estimates are within the range that NICE usually considers a cost effective use of NHS resources, taking into account the uncertain estimates. Therefore, cabozantinib is recommended as an option for treating advanced renal cell carcinoma in the NHS.
For more information see the committee discussion in the NICE technology appraisal guidance on cabozantinib for untreated advanced renal cell carcinoma.

Glossary

Eastern Cooperative Oncology Group
vascular endothelial growth factor

Paths in this pathway

Pathway created: December 2013 Last updated: October 2018

© NICE 2018. All rights reserved. Subject to Notice of rights.

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