Tailoring Therapy in Renal Cell Carcinoma

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Straight Talk on First-Line Therapies

Editor's Note: Given the explosion of drugs now available for the treatment of metastatic renal cell carcinoma (mRCC), oncologists are faced with an array of treatment options, but no direct comparative evidence on which drugs and drug sequences are likely to give the best outcome. Moreover, there are no established biomarkers that identify particular subgroups of patients most likely to respond to a given treatment. The choice of second- and third-line therapy must rely on evidence and the requirements of individual patients. Medscape spoke with Viktor Grünwald, MD, coauthor of a recent review on the treatment of mRCC,^[1] to get his perspective on how to make these choices.

Medscape: What are the available first-line options for mRCC, and what can patients expect to gain from these therapies?

Dr. Grünwald: There are several choices for first-line therapy outlined in the National Comprehensive Cancer Network (NCCN) guidelines for kidney cancer.^[2] These include the tyrosine kinase inhibitors (TKIs) sunitinib, pazopanib, and sorafenib; the mammalian target of rapamycin (mTOR) inhibitor temsirolimus; and immunotherapy with bevacizumab and interferon or high-dose interleukin-2 for selected patients. No matter which drug is used, only a minor fraction of patients achieve complete remission, and disease typically progresses on first-line therapy.

Medscape: What are the goals of first-line therapy?

Dr. Grünwald: The goals of therapy in mRCC are to maintain quality of life (QOL) and control the tumor. There is no cure for these patients.

All of the currently available options for first-line therapy have similar outcomes. Response rates are in the 30% range, and progression-free survival (PFS) is typically 8-11 months.

First-line therapy is the major opportunity to achieve response; responses to second- and third-line therapy are not as robust. I believe we can do better than this and increase the efficacy of first-line therapy with future studies.

We have no solutions so far, but checkpoint inhibitors might turn out to be an advance if we can define a population of patients with mRCC that can benefit from this approach. I can envision combination therapy with immunotherapy-based treatments, such as ipilimumab or nivolumab. This could be the next frontier in mRCC, but this approach is in preliminary clinical studies. Hopes are high for this approach.

Cite this: Tailoring Therapy in Renal Cell Carcinoma - Medscape - May 14, 2014.

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