At the 2022 European International Kidney Cancer Symposium (EIKCS) in Antwerp, Belgium at the weekend, there was a debate about the use of medicines as second treatments (second-line) and beyond for advanced kidney cancer. The evidence for the use of second-line treatments was presented in terms of time to when the treatment stopped working and overall survival time.

The evidence suggests that immunotherapy in the second line, following immunotherapy in the first line has limited effect on survival, although some patients respond well.

In conclusion, there is evidence to support the use of cabozantinib or nivolumab as a second treatment following first-line treatment with a TKI. Following first-line immunotherapy-based combination treatment, it was suggested that a TKI that had not been used as a first treatment be used. Limitations set by regulatory agencies must also be considered. Finally, immunotherapy as a first treatment followed by immunotherapy as a second treatment has not been investigated enough. Belzutifan appears to be a promising approach, but much more data is needed.

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The second debate considered the outlook for the patients after second-line treatment following first-line treatment with an immunotherapy combination, the increase of treatment after first-line treatment, whether all medicines can be considered the same as a second-line treatment, and what new treatment approaches may be coming along.

In conclusion, different modes of treatment were also considered, such as radiotherapy, ablation, medicines for the treatment of bone metastases, and treatments that change the gut bacteria to affect the immune system. It was made clear that currently there is no cure beyond first-line treatment with immunotherapy and there is no evidence favouring a particular TKI. Clinical trials of first- followed by second- and third-line treatments are long and difficult to do and real world data might be useful to look at the most effective sequence of medicines for advanced kidney cancer.

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