Why the First-Line Choice Carries Weight in RCC

Terence W. Friedlander, MD, of UCSF Helen Diller Family Comprehensive Cancer Center explains why he does not save effective drugs for later in advanced renal cell carcinoma (RCC), responding to Elizabeth R. Plimack, MD, MS, of Fox Chase Cancer Center. He cites an International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) analysis published this year in which only about 58% of patients reached second-line therapy, whether because of progression, comorbidities, or access to care. His goal is to make first-line therapy the only line a patient ever needs. When a patient has a large volume of disease or significant symptoms, he usually chooses a programmed cell death protein 1 (PD-1) inhibitor plus a tyrosine kinase inhibitor (TKI) for early control, noting that the TKI partners have not been compared head to head. He reserves dual immunotherapy for patients with a few lung metastases, slow-growing disease, or a strong reason to avoid a TKI, such as toxicity concerns.