National and international guidelines exist for the treatment of mRCC depending on subtype, IMDC prognostic group (see section on Prognostic stratification tools for patients with mRCC) and treatment line (ESMO, EAU, NCCN and DaRenCa). Most studies have primarily included patients with clear-cell histology, which is why there are guidelines for this patient group for 1st, 2nd and 3rd line treatment, whereas for non-clear-cell histology there are only recommendations for 1st line treatment.

Guidelines are continuously updated when new medicinal products/combinations are tested and approved. It should always be considered whether the patient can be included in a clinical trial.

In Denmark, treatment is in accordance with The Danish Medicines Council’s medicinal product recommendations and treatment guidelines concerning medicinal products for metastatic kidney cancer. For a link to the summaries of product characteristics for the individual medicinal products, refer to the section on targeted treatment and immunotherapy.

*CPI = Checkpoint inhibitor

There is no evidence for the most optimal treatment of each non clear cell subtype, as phase III studies have not been conducted exclusively for patients with non-ccRCC, either for the individual subtype or for the group as a whole. Data is obtained from large-scale studies’ subgroup analyses and expanded access programmes. Sunitinib (Sutent) has been shown to be most effective (level 2 evidence), but other VEGFR and mTOR inhibitors may also be effective.

Based on existing data, no recommendations can be made for later lines for patients with metastatic non-ccRCC. However, the treatment algorithm for ccRCC can be used – especially for papillary RCC, which is the most frequent subtype.

1. ESMO guildeline, DaRenCa guideline EUA guideline
2. Medicinrådet, https://medicinraadet.dk/media/eqenldkj/medicinr%C3%A5dets_behandlingsvejledning_vedr-_l%C3%A6gemidler_til_metastatisk_nyrekr%C3%A6ft-vers-_1-0_adlegacy.pdf