Expert oncologists share experiences and insights on key treatment protocols for patients with aRCC, including perspectives from community oncologists.
Dr. Robert Motzer: So now I think all of us we've had a fair amount of communication with community physicians in terms of what's been their experience with Len Pembro and Axi Pembro. And I don't know, Brian, what's been your takeaway from community physicians and some of the other programs you've done with those interactions as to their experience with say Lenvatinib plus pembro or the other TKI regiments?
Dr. Brian Rini: When I talk to community docs in forum like this or other forums, that there's fairly equal use of the four regimens, almost like there is among our academic community. There's the Ipi-Nivo diehards, immune therapy, we're definitely doing it. And then there's the IO-TKI camp and I like this one and you like that one. So I think you see that same, I don't want to say uncertainty, you see that same breadth of use across community physicians as well. When I talk about Lenvatinib dosing, nobody starts at 20 milligrams in the community and they're almost all doing what Betsy does. Either 14 or 10, and some go up and some just leave it there. And so again, I think I would love to give them more guidance, but we all do it differently. We don't know how to do it. So I think patients tend to end up at the right dose, I guess I'd say. And I'm not too worried that there's a bunch of people being underdosed out there that you're giving up efficacy. I think it's true if you start at 10 and didn't go up, there will be a fraction of patients underdosed in my opinion. But I think in general, patients via toxicity, etc. get to where they need to be, which is usually somewhere between 10 and 14.
Dr. Robert Motzer: And how about you, Betsy, in terms of the feedback from the community to you in terms of these regimens and what the obstacles are and what the concerns are and how they're doing? What's been your take on the view from the community?
Dr. Elizabeth Plimack: I think the community ironically has in a way more experience with these than we do because they dose it differently for different tumor types. So it's dose for endometrial, Lenvatinib is dose for a thyroid. And so they sort of have data that's different across diseases and experience within people who presumably would have the same set of side effects, maybe not different malignancies. But I think the art of managing side effects with these combinations, discerning what is the IO versus what is the TKI trying to decide, usually our first move is to hold the TKI, if we think it might be that and see if it gets better. If it does, then that implicates that drug, giving steroids if we think it's a severe autoimmune reaction, but not wanting to do that too soon or too late. There's just a lot that we've learned together and the three of us literally together from the very early days of the first combination studies in terms of how to give these. And so I do think while community practice, God bless them, they treat everything, there is a sort of art to understanding the particular disease and the particular drug and the combination in managing it that's only getting more complicated. And so I do hope they reach out to us with individual cases. And I think getting treated at a specialty center is also really good, or at least getting input there, because the list of side effects is really long. We all tell people you're never going to get all of them, but anything's possible. Call us and then we're reacting to phone calls and descriptions of things that could be either serious or benign. And as Brian said, he has a great care team helping him. That's also really important. So it is tricky and I think experience does help. And in some ways, the community has more experience and in some ways we have with this combination. Brian, any thoughts on that?
Dr. Brian Rini: I was just going to say, I think there's a learning curve to giving any drug or regimen. I think it takes you 10 or 12 patients to figure out at least maybe some of the nuances. So as we've said before in other forums, picking a regimen that you're comfortable with and know how to give and giving it well is the most important consideration. And then my other comments is, the one thing when I walk in the room and talk to the patient about a new regimen, like usually my fellow, my nurse, somebody's done all the hard work and talked about all the details, and I walk in and I say, listen, the one important thing is we don't have cameras in your house. If you have problems, you have to let us know. Send us a message on our portal during working hours. Here's my email, email me 24/7. Again, I say, if I'm sleeping, I won't answer you. But if you need attention, get it, you're not bothering us. Don't wait until Friday afternoon at 4:59 because then we're sending you to the ER. And you have to empower patients and sometimes patient spouses to tell on the patient when they're having problems. Because I think we'll all agree, early intervention is a key to toxic management, and not having a patient get so toxic that they end up in the ER, which is a disaster.
Dr. Elizabeth Plimack: It's always a partnership, as you say. Absolutely, care team and patient.