New First-Line Combination Therapies in Advanced RCC - Episode 3
Favorable-Risk mRCC: Sequencing Therapy
Best approaches to sequencing therapy for patients with favorable-risk metastatic renal cell carcinoma following first-line therapy with novel combinations such as ipilimumab and nivolumab.
Sumanta Kumar Pal, MD: You’re essentially taking the opposite stance of what Dave is saying. You’ll maybe go with a TKI [tyrosine kinase inhibitor] first in favorable-risk [patients], then to I/O [immuno-oncology] therapy. If I heard you correctly, are you still thinking that Sutent might be that drug? Is that from all these phase 3 studies? What are your thoughts there?
Thomas E. Hutson, DO, PharmD: It could be in the favorable-risk group. Your choices would include Sutent or Votrient. Axitinib is an option, but that’s somewhat off-label since it doesn’t have an indication in the frontline setting. You have cabozantinib, but its approval was in the intermediate- and poor-risk groups. So you don’t have a huge selection. If you go to NCCN [National Comprehensive Cancer Network] Guidelines, what are they listing? Sunitinib and pazopanib.
Sumanta Kumar Pal, MD: I’ll give you a chance to respond to that, Dave. What do you think? With favorable-risk [patients], are you going with Sutent?
David F. McDermott, MD: It comes down to whether you think kidney cancer is a curable disease. If you think metastatic kidney cancer can be knocked into remission and cured, then you go with the therapy most likely to do that and you save your palliative therapies for second line. Obviously, that’s not by the book. That’s not going by the NCCN Guidelines or the IMDC [International Metastatic Renal Cell Carcinoma Database Consortium] criteria. That’s not the rules that Dr Hutson implements at US Oncology. You asked me what I do. I try to aim for that, knowing that I’m going to fail most of the time. Right now, the PFS [progression-free survival] curve is above 30% and flat in CheckMate 214. OS [overall survival] is at 50% and flat. The benefits are pretty comparable across risk groups. Until the other combinations can produce those flat curves and firm tails on their curves, I’m going to go with ipilimumab-nivolumab. I hope to be shown that these other combinations are better. It’s just too early to say right now. In good-risk patients, there’s almost no evidence that they’re any better in an asymptomatic patient.
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