Bladder Cancer Update & Renal Cell Cancer Update, 2017 (Video Program)Selection of first- and second-line therapy for metastatic RCC
3:09 minutes.
TRANSCRIPTION:
DR LOVE: Let’s start out up front, first-line therapy in metastatic disease. How do you approach making a decision? DR RINI: So outside a clinical trial, sunitinib and pazopanib are the standards of care. And it honestly has as much to do with kind of the timing of when the drugs were developed and the way the trials were run than that they’re the best TKIs, per se. But I think most people have accepted them as the standard of care. And sunitinib is the control arm of all the large Phase IIIs that are going on now with the checkpoints. In the US, my understanding, it’s fairly evenly split between them. We tend to be sunitinib users, mostly because being involved in the early trials and really a high level of confidence about how to dose adjust and schedule adjust, as we talked about, supportive care management. I tend to choose pazopanib for the older, more comorbid patient. I know some other folks do that. It’s probably not fair. It’s not necessarily based on data; it’s just sort of that sense of what people can tolerate. I think the field has moved beyond that question now, again with the emergence of checkpoints, which we’ll talk about. I think that’s the background. I don’t think it’s an interesting question anymore. I think either one is fine. DR LOVE: What about beyond first line? How do you decide about the next TKI? Maybe you’re going to give a checkpoint inhibitor in between. And particularly, maybe you can talk a little bit about the data that’s come out recently with cabazitaxel and lenvatinib and how you utilize these agents, if at all, in your practice. DR RINI: Sure. So I tend to use nivolumab second for most of patients. It has, obviously, Level 1 evidence of a survival benefit. And it is exceedingly well tolerated. Having given TKIs for a decade plus and then now giving that agent, I’m really struck that patients who come in having gotten a previous TKI and now are on nivolumab almost uniformly tell me how great they feel, probably not because of nivolumab, per se, but just because they’re off their previous therapy and they didn’t realize how bad they felt, honestly. So because of the risk-benefit ratio, I think is very much in its favor. And unless there’s a good reason not to, I would say probably 8 or 9 out of 10 patients in my practice will get nivolumab second. After nivolumab, we don’t really know. There’s not any prospective data. There are a couple of retrospective data sets on TKIs after nivolumab — not surprisingly, they have activity. I don’t think we know that one is better than the other in that setting. We’re doing a trial of axitinib in that setting. I think any TKI would have activity. Axitinib has tended to be used after nivolumab, in part based on data from the AXIS trial and previous axitinib studies suggesting that it had a great effect after cytokines, that after high-dose IL-2 and interferon it seemed to have a particularly robust effect. And I don’t know whether that has anything to do with the drug itself or just the fact that it’s one of the only agents to be studied in that setting. So that’s often our go-to drug after nivolumab. Cabozantinib we’ve started to use a little more in that setting. I tend to use it in later lines of therapy. Lenvatinib/everolimus I’ve not used. I’m a little skeptical of the efficacy data, and its toxicity is very substantial. |