A 69-Year-Old Woman With Advanced Renal Cell Carcinoma - Episode 4
Chung-Han Lee, MD: There are triggers we would usually have in terms of frontline therapies and changing the frontline therapies. We continue these medications on an ongoing basis so long as the patients are deriving clinical benefit, defined by a lack of progression, no new lesions, no growth of the existing lesions, or very slow growth of new lesions, and also a question of tolerability. We want to have that all to be true, whereas if we notice that the disease was growing in some sort of way or patients were having difficulty from a tolerability standpoint, then that certainly would trigger us to think about switching treatments.
Right now in terms of what we would do as second-line treatment, a lot is based on what treatments they’ve had in the past and how they did on the treatments. In this patient in particular, they were started on a single-agent TKI [tyrosine kinase inhibitor] because they had favorable-risk disease, and from a time standpoint, combining immunotherapy [I-O] was not necessarily an option. However, they had an outstanding response to a single-agent TKI. Typically speaking, a long-term responder to a single-agent TKI is about 18 months, and the patient certainly exceeded that, and went on for more than double what the median progression-free survival was on a single-agent TKI, suggesting that there’s probably a strong VEGF component to their disease. We take that into consideration in whether or not to stick with additional VEGF-targeted therapy or think about switching to some sort of I-O-containing regimen.
In thinking about second-line therapy, the options for this patient after having been on a single-agent TKI include a single-agent checkpoint inhibitor, such as nivolumab, could consider cabozantinib as monotherapy, could consider lenvatinib plus everolimus as a combination therapy targeting both the mTOR and VEGF signaling pathways, or even other second-line TKI therapies.
Transcript edited for clarity.
Treatment and follow-up