Over the past couple of years there have been several approvals of new treatments and drug combinations for advanced/metastatic renal cell carcinoma (RCC) resulting in treatment plans that are tailored for the individual patient.

Recent advances in the treatment of advanced/metastatic RCC include cabozantinib, nivolumab/ipilimumab, pembrolizumab/axitinib and avelumab/axitinib. Dr Ajjai Shivaram Alva, associate professor at the University of Michigan, said “For kidney cancer, we have to treat the patient on an individual basis with regards to the context of the prognostic score by the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC), the histology, and the individual patient’s performance status.”

Cabozantinib is a viable first-line option, especially for those who cannot tolerate alternative treatments, such as immunotherapy, or have contraindications to immunotherapies, such as autoimmune diseases or previous organ transplants.

Dr Alva noted that “More data are needed, especially with all the changes in the first- and second-line spaces, particularly with the immunotherapy combinations,” Alva said. “There is an ongoing trial of cabozantinib in combination with nivolumab that is expected to read out very soon. The field may completely change (with those data).”

However, although the increased toxicity of combinations should be managed very carefully, this individual-based approach could completely change the treatment of advanced/metastatic RCC.

“Combinations have already started to occupy a greater share of the number of patients being treated,” Dr Alva said. “Monotherapy will still have its role, but it’s probably going to be diminishing.” He added: “The bigger questions in the upcoming years is what to use after a TKI and immunotherapy combination. What do we go to next? Maybe it’s a separate class of drugs. Some are being tested in trials, such as metabolic inhibitors, glutamine inhibitors, and arginine-based inhibitors. There are also new molecules attacking HIF1A, so those could be classes of drugs that would have to be explored for post-combination progression.”

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