Choosing Therapy for mRCC

Neeraj Agarwal, MD:So, what factors did I keep in mind when I was making a treatment decision for this patient? I think the first one was the IMDC risk factor—how many risk factors she had. She had 2 risk factors: presence of onset of metastatic disease within 1 year of surgery—within 1 year of diagnosis of localized kidney cancer—and high calcium. However, I also looked at her performance status. She was doing really well. She did not have really a lot of symptoms. She wanted to have an independent lifestyle. She did not want to visit me in the hospital multiple times. And, very importantly for me, the tumor did not express PD-L. So, upon PD-L1 testing, the tumor expression of PD-L1 was less than 1%, so those were the factors that I kept in mind while making a clinical decision for cabozantinib in this case.

For this patient with a newly diagnosed metastatic renal cell carcinoma, how do I pick which 1 to choose from? I have sunitinib, pazopanib, and cabozantinib. And very soon, nivolumab with ipilimumab will be approved.

Transcript edited for clarity.

Case Scenario: A 73-year old female with rapidly progressing mRCC

March 2017

• A 73-year old woman with clear cell RCC, hyperlipidemia, and type 2 diabetes, which are both managed medically
• Her baseline patient and disease characteristics were:
  • ECOG PS 0, KPS 90
  • pT3bNxM0 (AJCC stage 3)
  • 5-cm left kidney tumor mass with extension into the left renal vein
• She underwent radical nephrectomy within 1 month following diagnosis

December 2017

• The patient reported loss of appetite and weight loss
• CT imaging showed multiple liver lesions, 2 small nodules in the right lung upper lobe, and mediastinal lymphadenopathy
• Laboratory findings notable for Ca2+ 14.8 mg/dL
• PD-L1 expression, <1%
• Remarks: RCC disease progression; IMDC risk stratification, intermediate
• The patient was started on cabozantinib, 60 mg daily
• After 4 weeks on therapy she developed grade 2 diarrhea and her dose was reduced to 40 mg