During this online interview, the approach to selection of first-line treatment for patients with metastatic renal cell carcinoma (RCC) was discussed.  Traditionally, the selection of initial treatments was very straightforward, and patients were treated with vascular endothelial growth factor (VEGF) tyrosine kinase inhibitors, (TKIs) such as sunitinib and pazopanib.

Over the past 2 years, decisions have become more difficult with the recent approval of novel treatment combinations. First-line immunotherapy-based combinations have led to a new treatment paradigm in the first-line treatment of metastatic RCC. There are now multiple immunotherapy/immunotherapy combinations and immunotherapy/VEFG-TKI combinations to choose from, e.g., nivolumab and ipilimumab, axitinib and pembrolizumab, and avelumab and axitinib.

The approach to selecting the first treatment is the source of debate amongst clinicians. In this interview, Dr Gong from Cedars-Sinai Medical Center in California suggests that for patients with bulky symptomatic tumours, the preference is to go with the VEGF-TKI plus immunotherapy combination to get a response and reduce the size of the tumour. However, for patients who do not need a rapid reduction in the size of their tumour, especially in a young, fit patient, then the preference is ipilimumab plus nivolumab because of the high complete response rate for this combination. Treatment needs to be tailored to the patient’s existing medical conditions, side effects and risk of the disease (poor, intermediate and favourable).

VEGF-TKIs may not be the best treatment for patients with heart problems, and immunotherapy cannot be used in patients with autoimmune conditions, as well as organ transplant patients. Active surveillance could be used for patients with favourable and intermediate risk factors and no more than one to two metastases, e.g., in the lung only. The size of the tumour also needs to be taken into account and the sum diameter of all the tumours should be less than 5 cm. However, more clinical trials need to be done to determine the best treatments to use in the first-line.

Listen to the interview on Practice Update here