Changing Paradigms in the Treatment of Renal Cancer

Oncology & Hematology Review. 2018;14(1):20 DOI: https://doi.org/10.17925/OHR.2018.14.1.20
Keywords: Renal cell carcinoma, ipilimumab, nivolumab, interleukin
Disclosure: Ulka Vaishampayan has nothing to disclose in relation to this article.
Review Process: This is an expert opinion piece and has not been submitted to external peer reviewers.
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Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit. © The Authors 2018.
Received: March 16, 2017 Citation Oncology & Hematology Review. 2018;14(1):20 DOI: https://doi.org/10.17925/OHR.2018.14.1.20
Correspondence: Ulka Vaishampayan, Karmanos Cancer Center, Wayne State University, Detroit, MI 48201, US. E: vaishamu@karmanos.org
Support: No funding was received in the publication of this article.

Q. What are the currently approved treatment options for newly diagnosed patients with metastatic renal cell carcinoma (RCC)?

The currently approved therapies are of two different types: targeted therapy and immunotherapy. Between 2005 and 2014 the backbone of therapy in RCC was anti-angiogenic therapy and in 2015 immune therapy in the form of immune checkpoint inhibitors began to get US Food and Drug Administration (FDA) approval. Currently there are about nine agents/regimens approved for RCC.

Q. How have the emergence of immune checkpoint inhibitors and targeted therapies affected the treatment paradigm for first-line treatment of RCC?

The treatment efficacy has improved remarkably and there is now the hope of long-term remission in metastatic RCC.

Q. What was the most exciting data to emerge in the past year supporting the use of these agents?

The most exciting data is from a study evaluating the combination of ipilimumab and nivolumab, which showed a long (>30 months) median overall survival. So the life expectancy in advanced RCC has about tripled in the last 20 years.1

Q. What patient factors would influence your choice of first-line agent?

There is an International Metastatic Renal-cell Carcinoma Database Consortium (IMDC) model and I use the risk stratification from this when I evaluate patients.2 Now that we have potential options such as bevacizumab and atezolizumab in combination showing efficacy in programmed death-ligand 1 (PDL-1) positive patients, this test may be worthwhile getting. Patients with bone metastases, symptomatic or rapidly progressive aggressive disease will likely need cabozantinib, a vascular endothelial growth factor (VEGF) and c-Met inhibitor tyrosine kinase inhibitor with an 80% chance of shrinking tumors.

Q: Is there still a place for high-dose interleukin (IL) in the treatment paradigm?

I still evaluate for front-line interleukin as this agent still has the longest track record of showing long-term remissions with 20-year follow up. Only about 10% of my patients with metastatic RCC will be candidates for IL-2.

References:
  1. Motzer RJ, Tannir NM, McDermott DF, et al. Nivolumab plus ipilimumab versus sunitinib in advanced renal-cell carcinoma. N Engl J Med. 2018;378:1277–90.
  2. Heng DY, Xie W, Regan MM, et al. Prognostic factors for overall survival in patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor-targeted agents: results from a large, multicenter study. J Clin Oncol. 2009;27:5794–99
Keywords: Renal cell carcinoma, ipilimumab, nivolumab, interleukin