A Sign of the Times: The Changing Treatment Landscape for Advanced Kidney Cancer

The treatment landscape for advanced kidney cancer has changed dramatically over the past few years, with several targeted drugs and an immunotherapy approved by the FDA.
BY MARIJKE VROOMEN DURNING, RN
PUBLISHED: SEPTEMBER 23, 2016
Whenever 60-year-old Catherine Messinger experienced pain in her side, she would chalk it up to diverticulitis, a condition that had plagued her for many years. But in April 2013, her intense pain signaled something else. Messinger, whose doctor initially suspected a kidney stone, had a tumor on her kidney and was diagnosed with stage 4 renal cell carcinoma (RCC), or kidney cancer.

After Messinger underwent several months of scans to monitor her progress, a new tumor was found in her spine and, in January 2014, despite initial treatment, her doctors found that the tumor had spread to her abdomen. Messinger needed innovative treatment, and, luckily, she qualified for the one spot her oncologist, Elizabeth Plimack, M.D., M.S., had in an immunotherapy trial at Fox Chase Cancer Center in Philadelphia, Pennsylvania.

“The trial sounded really promising, so I agreed to do it,” Messinger says of the ongoing phase 1 study, which is considering the best dosing for the immunotherapy Opdivo (nivolumab) when it’s combined with targeted drugs Sutent (sunitinib) or Votrient (pazopanib), as well as the effectiveness of Opdivo given with either Sutent, Votrient or another immunotherapy, Yervoy (ipilimumab). Two- and-a-half years later, Messinger is still taking her immunotherapy regimen.

Yervoy is an immune checkpoint inhibitor, which blocks the protein CTLA-4 on T cells. The job of CTLA-4 is to help hold the body’s immune system in check; blocking its activity frees up a patient’s immune system to work more powerfully to kill cancer cells. Opdivo is another checkpoint inhibitor that works on the same principle, but targets a different protein, PD-1. These drugs can slow tumor growth or even shrink tumors.

Messinger, who goes to the clinic for assessment and treatment every two weeks, is experiencing a few side effects from her treatment, but nothing that makes her feel she needs to discontinue it.

“I’m really tired and, just lately, my joints and bones have started hurting. They don’t know if it’s the nivo or because I’m 60,” she says. “I get nauseated now and then, but for the most part, it’s really not been a bad ride at all.”

Both Yervoy and Opdivo have been approved for at least a couple of years to treat other cancers, but it was only recently that Opdivo was given the green light by the U.S. Food and Drug Administration (FDA) for use in patients with advanced RCC. That happened in November 2015, based on findings from a phase 3 trial, which showed longer overall survival and fewer serious side effects with Opdivo than with another newer treatment, the targeted drug Afinitor (everolimus). Opdivo can cause side effects including fatigue, itching, rash, upper respiratory problems, swelling of the hands and feet, gastrointestinal disturbances, muscle pain, fever, and abdominal, chest or joint pain.

“This drug works by stimulating the body’s immune system in a much more specific fashion than previous generations of such treatments, to elicit an immune response,” says Sumanta Kumar Pal, M.D., assistant clinical professor in the Department of Medical Oncology & Therapeutics Research and co-director of the Kidney Cancer Program at City of Hope in Duarte, California. “When you look at the older classes of immune- based treatments, like IL-2 (interleukin-2) and interferon, these were incredibly toxic. There were many toxicities that ultimately might lead to death. This is far different with the targeted, immune- based therapies that we have now in the clinic. By and large, I’ve found that patients are able to maintain their quality of life. It always helps to have tight oversight by a physician who is knowledgeable of these medications. If you do have that, then certainly, you can still enjoy excellent quality of life while extending survival.”



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