Therapeutic Approach for Metastatic Renal Cell Carcinoma - Episode 3
Neeraj Agarwal, MD:What is the rationale for choosing cabozantinib over the ipilimumab/nivolumab combination in this patient? So, first of all, the ipilimumab/nivolumab combination is not available. It’s not FDA approved. Moving forward 2 months or 3 months, assuming this combination is approved, I still think cabozantinib would be a better choice in this given patient because the PD-L expression of the tumor was less than 1%. And if we look at the CheckMate-214 trial data, the progression-free survival was not experienced by those patients whose tumor did not express PD-L1. So, in my view, for this given patient, cabozantinib would be a better choice.
So, regarding safety and toxicity of cabozantinib versus the ipilimumab/nivolumab combination, I think these drugs are very different with their own safety and toxicity profile. Cabozantinib is a very traditional VEGF TKI, which also targets AXL and MET. And accordingly, we see toxicities more in line with VEGF TKIs, such as hand-foot syndrome, hypertension, fatigue, diarrhea, and so on. On the other hand, the ipilimumab/nivolumab combination is a very novel combination. It is an already established combination in metastatic melanoma, but for GU oncologists, it’s a very novel combination with its own novel set of side effects and safety profile. Safety toxicity profile of the nivolumab/ipilimumab combination is very different from a TKI like cabozantinib. We are mainly talking about autoimmune side effects. So, if we look at the CheckMate-214 trial, 60% of patients required frequent treatment with corticosteroids, which is, in my view, a relatively higher use of steroids, more than I have practiced in my clinic with single-agent nivolumab.
Transcript edited for clarity.
Case Scenario: A 73-year old female with rapidly progressing mRCC