Sandy Liu, MD, outlines the available second-line therapeutic options for renal cell carcinoma, or kidney cancer, as well as what factors she considers when selecting from agents in this setting.
PUBLISHED June 18, 2018
Sandy Liu, MD: If I start a patient on a first-line targeted agent, there are just 2 reasons why I would stop a first-line treatment or why it would be unsuccessful. First is if they’re really not able to tolerate the medication. If the side effects, despite aggressive management — dose withholding and dose reduction — are not able to be tolerated, I would stop the therapy and deem it unsuccessful. The second reason why I would stop therapy in the first-line setting is because of progression of disease. When I start a therapy, I will typically repeat imaging every 3 months to monitor their response to treatment. If I see that the tumor is getting bigger or if there are new tumors popping up, then I would deem it unsuccessful and change to a second-line therapy. There are many options for second-line therapy.
Options for second-line therapy for patients who progress during first-line therapy or can’t tolerate first-line therapy would be another targeted agent. There are several. There are about 6 or 7 targeted agents approved for kidney cancer. I would move on to the next targeted agent. If they had Votrient (pazopanib), I would use Sutent (sunitinib). Cabozantinib would be another great second-line drug. Nivolumab, which has a completely different mechanism from the targeted agent—it’s an infusion immunotherapy through IV—is another good option as second-line treatment. Another class of agents is the mTOR (mechanistic target of rapamycin) inhibitors. There’s temsirolimus, which is an IV agent, and everolimus, which is an oral agent. That is a potential option. However, in the second- and third-line setting, I definitely do consider patients for a clinical trial whenever possible.
Quality of life factors most importantly in my decision making when I recommend a treatment option, because these treatments are not benign. They do have side effects. If I see a patient and I know that they’re going to struggle with a medication and it’s going to be a class effect—and the side effects are generally the same—I tend to go to another class like immunotherapy in the first or second-line setting. Generally, immunotherapies do have their own side effects, but the side effects are different from the targeted agents. They’re much more tolerable. I have given immunotherapy to 80- or 90-year-olds, and they do pretty well. If the side effect profile really interferes with their quality of life, I generally tend to take that into consideration and recommend an alternative therapy.
There are other factors that I consider. We haven’t talked about different types of kidney cancers. The most common type is clear cell, which makes up about 75% to 80%. There are non-clear cell renal cell carcinomas that don’t have a good, clear standard of care, and we treat them as clear cell disease because there are really not a lot of good options. So, if I see a patient who has non-clear cell disease like papillary or chromophobe or collecting duct carcinoma, I treat them completely differently sometimes. I definitely consider them for a clinical trial, but if they don’t have any other options, I basically treat them like a patient with clear cell disease.