Selecting First-Line Therapy in Advanced RCC

Elizabeth R. Plimack, MD, MS, of Fox Chase Cancer Center opens this CancerNetwork Training Academy discussion on first-line treatment decisions in advanced renal cell carcinoma (RCC) with Terence W. Friedlander, MD, of UCSF Helen Diller Family Comprehensive Cancer Center, and Moshe C. Ornstein, MD, MA, of Cleveland Clinic. Dr Plimack notes that dual checkpoint blockade and checkpoint inhibitor plus vascular endothelial growth factor (VEGF) receptor–targeted combinations all improved outcomes over single-agent tyrosine kinase inhibitor (TKI) therapy in phase 3 trials. Dr Friedlander weighs histology, International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk, and the burden and tempo of disease. For very symptomatic patients he favors a TKI-based combination, citing response rates of almost 70% with lenvatinib plus pembrolizumab vs about 39% to 40% with ipilimumab plus nivolumab. He also considers comorbidities, chronic TKI toxicity, patient goals, the chance of a durable response with no daily pill, and local therapy for a resectable lung metastasis.