During the American Society of Clinical Oncology Annual Meeting earlier this week, there was a discussion about the sequencing of treatments for advanced/metastatic kidney cancer. Various poster presentations were considered, and the order in which to take medication after surgery was discussed. This included adjuvant pembrolizumab after surgery and the use of various combination therapies for metastatic kidney cancer.Various considerations were identified during the sequencing of treatments after surgery for metastatic kidney cancer:
  • The sequencing of treatments for metastatic kidney cancer has changed with the introduction of immunotherapy combinations
  • There are no randomised clinical trials to look at what to do when immunotherapy combinations stop working when they are given as the first treatment after surgery (several clinical trials are ongoing)
  • After immunotherapy-immunotherapy combinations, patients are progressing on one type of medication with one type of action
  • After immunotherapy-targeted therapy combinations, patients are progressing on two types of medication with two types of action
  • Guidelines recommend a targeted therapy (tyrosine kinase inhibitor, TKI) that has not been used before as a second treatment after the combinations stop working
  • When do we consider a patient to be resistant to immunotherapy after they complete their treatment and their cancer gets worse?

In summary, the the following take-home messages were discussed:

  • Results from clinical trials looking at the survival of patients on their second treatment following immunotherapy combinations as a first treatment show long-term benefit of these combinations in patients with metastatic kidney cancer
  • The sequencing of treatments has changed with the introduction of immunotherapy combinations, and data from phase 3 studies are awaited
  • After immunotherapy combinations, a targeted therapy (TKI) currently has the strongest evidence as a second treatment
  • Ongoing trials may provide more information about maintenance immunotherapy.