The increase in the number of first-line treatments for metastatic renal cell carcinoma (RCC) over the past 3 years has had meaningful effects on the choice of second-line treatments. Dr Camillo Porta from the University of Pavia in Italy discussed the selection of second-line and later treatments in a presentation at the European International Kidney Cancer (EIKC) 2021 Virtual Annual Meeting.
In his presentation, Dr Porta discussed the appropriate second-line treatment following treatment with a vascular endothelial growth factor (VEGF) inhibitor, such as sunitinib, an immunotherapy/immunotherapy combination, such as nivolumab/ipilimumab and a combination immunotherapy/VEGF inhibitor treatment, such as pembrolizumab/axitinib.
Following first-line treatment with a VEGF inhibitor, there are many available choices, the standard of care being nivolumab or cabozantinib. Dr Porta suggested that if an early response is needed, cabozantinib may be preferred while if it is reasonable to wait, nivolumab may be able to give long-term benefits.
After first-line immunotherapy combination there is only one prospective study looking at axitinib. Time to when the drug stopped working and the cancer started growing again (progression-free survival) was 8.8 months and axitinib showed robust clinical activity.
Retrospective data from other studies with VEGF inhibitors or mTOR inhibitors (everolimus) show some clinical benefit of using these medicines in the second line after immunotherapy combinations.
In conclusion, Dr. Porta suggested that any VEGF inhibitor (if not used in the first line) may be effective, but there is evidence to suggest that immunotherapy may work following initial immunotherapy. However, he emphasised the need for more studies using biomarkers to determine the best approach for individual patients.