Risk stratification and treatment algorithm for metastatic renal cell carcinoma

The systemic treatment of metastatic renal cell carcinoma has continuously evolved over the last two decades. Significant improvements in overall survival and quality of life of patients with advanced disease have been observed. With the approval of combination treatment with programmed cell death protein (ligand) 1 (PD-L1) and immune checkpoint inhibitors (ICI) as first-line treatment in 2019, the previous standard vascular epidermal growth factor receptor-tyrosine kinase inhibitor (VEGFR-TKI) monotherapy has been replaced as the primary treatment option. In addition to immunotherapy with nivolumab and ipilimumab, four VEGFR-TKI/ICI combinations are now approved. The selection of treatment should be preceded by a risk stratification using defined criteria from the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC). Clinical parameters as well as a detailed patient counselling on differences in the efficacy profile (response rate, long-term progression-free survival), potential side effects and impact on the quality of life help to make an individual treatment decision and to maximize the benefits of a strategy.