Topic: Advanced Disease

Robert R. Dreicer, MD, MS, MACP, FASCO, Associate Director for Clinical Research and the Deputy Director of the University of Virginia Cancer Center, discusses the challenges in picking an optimal front-line regimen for the treatment of renal cell carcinoma and the impact of adjuvant immuno-oncology (IO) therapy. He cites data from four trials (CheckMate 214, Keynote-426, CheckMate 9ER, and CLEAR) before outlining the challenges in choosing an optimal front-line regimen. Dr. Dreicer points out that there is no comparative data currently available before explaining that tyrosine kinase inhibitors (TKIs, formerly the standard of care for kidney cancers) are toxic, challenging drugs that impact a patient’s quality of life. Dr. Dreicer outlines the therapies available today, including ipilimumab plus nivolumab (IPI-NIVO) which he characterizes as challenging for the first couple of months but well-tolerated in the last ~20 months during which patients undergo a maintenance regimen of nivolumab. He points out that treatment can be stopped after two years for patients that respond well. Dr. Dreicer asserts there is no equivalent conclusion with a TKI checkpoint. Dr. Dreicer then turns his discussion to the KEYNOTE-564 study on pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for patients with renal cell carcinoma. He outlines the study design and eligibility criteria before displaying the disease-free survival (DFS) data showing the adjuvant therapy resulted in a 32 percent reduction in recurrence or death. Dr. Dreicer argues that for patients who can access an IO-based regimen, IPI-NIVO should be the standard of care, advising that while there is not one “right answer” to the optimal treatment question, practitioners ought to use one regimen, figure out what it’s toxicities are, and learn how to use it well. Dr. Dreicer then outlines questions that will emerge if an adjuvant checkpoint inhibitor becomes a standard of care, citing disruption to the front-line paradigm, the role of subsequent IO therapy, progression while on adjuvant therapy, and progression following adjuvant therapy. Dr. Dreicer emphasizes the need for other trials and the need to develop therapeutics that work in immune-checkpoint resistance.