Matching First-Line Combinations to Disease Pace and Burden

Moshe C. Ornstein, MD, MA, of Cleveland Clinic says clinicians cannot yet predict which patient with advanced renal cell carcinoma (RCC) will respond better to dual immune checkpoint blockade or to immunotherapy plus a tyrosine kinase inhibitor (TKI), in a discussion moderated by Elizabeth R. Plimack, MD, MS, of Fox Chase Cancer Center. He looks first at histology and often gives ipilimumab plus nivolumab to patients with sarcomatoid features, citing strong response and survival data. Beyond histology, he asks what the burden and pace of disease mean for the next 3 to 9 months rather than the 10-year tail of the survival curve. Noting that the trials were not compared directly, he cites consistently higher response rates and progression-free survival with immunotherapy plus TKI, and says about 1 in 5 patients have progression as their best response to ipilimumab plus nivolumab. He leans toward immunotherapy plus TKI when a response is needed and toward dual immunotherapy for lower-burden disease.