Evolution of Care in Advanced Kidney Cancer

Brian Rini, MD

Which Agent First-Line?

With seven targeted therapies approved for metastatic renal cell carcinoma (RCC), researchers and drug developers are now focusing on understanding the best way to sequence these therapies—and on identifying predictive biomarkers of response.Six of these agents are oral and fall into two categories: multi-tyrosine kinase inhibitors against the vascular endothelial growth factor (VEGF) or inhibitors of the mammalian target of rapamycin (mTOR). Based on recent phase III randomized, large clinical trials, two VEGF inhibitors are now the standard of care for first-line RCC.

Sunitinib was the first VEGF inhibitor approved for RCC and is still widely used as a result of strong clinical data showing greater progression- free survival (PFS) and overall survival (OS) in treatment-naïve patients compared to interferon alfa.¹The second widely used oral VEGF inhibitor is pazopanib; studies have demonstrated that pazopanib improved PFS in treatment-naïve metastatic RCC compared to placebo.²

The recent phase II RECORD-3 trial,³comparing first-line everolimus, an mTOR inhibitor, followed by sunitinib to the reverse sequence, showed that treatment with sunitinib first produced longer PFS for patients.

The COMPARZ trial,⁴reported at the 2012 annual European Society for Medical Oncology (ESMO) Congress in Vienna, Austria, directly compared the efficacy of pazopanib to sunitinib in patients with metastatic, treatmentnaïve RCC. While both drugs demonstrated similar efficacy (31% overall response rate in the pazopanib arm vs 25% in the sunitinib arm; 28.4 months OS in the pazopanib arm vs 29.3 months in the sunitinib arm), patients perceived pazopanib to have a better side-effect profile compared with sunitinib. Patients on pazopanib had less hematological toxicity, hand-foot syndrome, rash, fatigue, and peripheral edema.

From their experience at the Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Jenny J. Kim, MD, assistant professor of Oncology, said that both sunitinib and pazopanib are being used in the frontline setting for these patients, although these agents have slightly different side-effect profiles. Kim and her colleagues have noticed that in their experience, patients tend to have more hand-foot syndrome and stomatitis with sunitinib and more liver toxicity with pazopanib. With the approval of pazopanib in 2009, it has been well incorporated along with sunitinib into the gastrourology practice at Johns Hopkins in the treatment of metastatic RCC.

“There is a trend towards favoring pazopanib recently,” said Kim. “This is most likely due to a lack of handfoot syndrome, which seems to affect patients’ day-to-day quality of life.” This observation in clinical practice is consistent with what was seen in the COMPARZ trial.

It is important to mention, Kim noted, that discontinuation rates were similar for both sunitinib and pazopanib in the study, although patient subjective toxicity experience was better with pazopanib. One potential explanation may be that there were higher liver toxicities with pazopanib compared with sunitinib, which led to discontinuation of pazopanib in the trial.

Targeted Agent Sequencing

Another small, 168-patient study, the PISCES trial,⁵reinforced the COMPARZ trial data, showing that 70% of patients on the trial preferred pazopanib while 22% preferred sunitinib. “While these trials are not perfect, they will likely have an impact on the oncologic community as more ‘tangible’ data comparing the two agents,” said Kim.Although second-line and subsequent therapies become gradually less effective, axitinib, sorafenib, and everolimus are all options for second-line therapy. “The only drug that has been tested exclusively in a second-line setting is axitinib,” said Brian Rini, MD, professor of Medicine at Case Western Reserve University and a practicing oncologist at the Cleveland Clinic Taussig Cancer Institute in Cleveland, Ohio. Axitinib is a VEGF inhibitor approved for metastatic RCC after failure of one systemic therapy; approval was based on the AXIS trial.⁶For patients who had previously failed sunitinib, axitinib significantly delayed PFS for 2.6 months longer compared with sorafenib.

“Clinical trials point to the importance of clinicians to maximize each oral targeted agent and to expose patients to multiple drugs over the course of metastatic disease,” said Rini. When to switch a patient’s therapy in the clinical setting remains a challenge, as the timing of the switch from one therapy to another has not been formally tested. A specific and potent sequencing regimen probably does not exist with the current drugs we have, unfortunately, said Rini.

PFS versus OS?

According to Kim, all of these agents are being used in the second-line setting because there is a lack of complete cross-resistance among them. “At this point, without robust biomarkers of response, exposure to all different agents is probably key for the patients’ best clinical outcome,” said Kim.The recently announced phase III INTORSECT trial compared temsirolimus, an mTOR inhibitor, to sorafenib, a VEGF inhibitor, in patients previously treated with sunitinib.⁷Although there was no difference in PFS, patients on sorafenib had a longer OS compared with those on temsirolimus.

The Next Wave of Therapies

“This result raises a major question,” said Kim. “Is PFS a valid endpoint for these trials or should we be using OS as a better measure of efficacy?”The checkpoint inhibitors currently in development are clearly promising, said Rini. “These are the next wave of effective kidney cancer therapies.” According to Rini, effectiveness of anti-VEGF therapy may have reached a plateau and the development of the immunotherapy checkpoint antibodies are revitalizing kidney cancer research, providing patients with a chance at durable, potentially longterm responses.

Results from a phase I trial with the anti-PD-1 antibody nivolumab (BMS- 936558) show that the immunotherapy can produce responses in approximately 30% of heavily pretreated patients, and that the responses are durable.⁸Nivolumab is now being tested in a phase III trial in pretreated advanced or metastatic RCC.⁹Two other immunotherapy checkpoint agents, MPDL3280A and lambrolizumab, are currently in phase I trials for solid tumors. “There have been great results so far with nivolumab,” said Kim.

Although most combinations of targeted agents have proven to be disappointing either due to toxicity or lack of improved efficacy, checkpoint inhibitors may provide renewed promise in the combinatiorial efforts, according to Kim.

“Within the last decade, we have almost tripled the lifespan of metastatic RCC patients,” said Kim. The checkpoint inhibitors now have the potential to turn kidney cancer into a chronic disease, she said.

The next questions for both the newer immunotherapies and targeted oral drugs is how to best identify patients who are most likely to respond. There are no biomarkers yet, but intensive research to identify them is under way.

References

1. Motzer RJ, Hutson TE, Tomczak P, et al. Overall survival and updated results for sunitinib compared with interferon alfa in patients with metastatic renal cell carcinoma.J Clin Oncol. 2009;27(22):3584-3590.
2. Sternberg CN, Davis ID, Mardiak J, et al. Pazopanib in locally advanced or metastatic renal cell carcinoma: results of a randomized phase III trial.J Clin Oncol. 2010;28(6):1061-1068.
3. Motzer RJ, Barrios CH, Kim TM, et al. Record-3: phase II randomized trial comparing sequential first-line everolimus (EVE) and second-line sunitinib (SUN) versus first-line SUN and second-line EVE in patients with metastatic renal cell carcinoma (mRCC).J Clin Oncol. 2013;31(suppl, abstract 4504).
4. Motzer R, Hudson TE, Reeves J, et al. Randomized, open-label, phase III trial of pazopanib versus sunitinib in first-line treatment of patients with metastatic renal cell carcinoma: results of the COMPARZ trial. Presented at: the 2012 European Society for Medical Oncology Congress; September 28-October 2, 2012; Vienna, Austria.Ann Oncol. 2012;23(suppl 9; abstr LBA 8).
5. Escudier BJ, Porta C, Bono P, et al. Patient preference between pazopanib (Paz) and sunitinib (Sun): results of a randomized double-blind, placebo- controlled, cross-over study in patients with metastatic renal cell carcinoma (mRCC)—PISCES study. Presented at: the 2012 American Society of Clinical Oncology Annual Meeting; June 1-5, 2012; Chicago, IL.J Clin Oncol. 2012;30(suppl; abstr CRA4502).
6. Motzer RJ, Escudier B, Tomczak P, et al. Axitinib versus sorafenib as second-line treatment for advanced renal cell carcinoma: overall survival analysis and updated results from a randomised phase 3 trial.Lancet Oncol. 2013;14(6):552-562.
7. Hutson T, Escudier B, Esteban E, et al. Temsirolimus vs sorafenib as second line therapy in metastatic renal cell carcinoma: results from the INTORSECT trial. Presented at: the 2012 European Society for Medical Oncology Congress; September 28-October 2, 2012; Vienna, Austria.Ann Oncol. 2012;23(suppl 9; abstr LBA22).
8. Drake CG, McDermott DF, Sznol M, et al. Survival, safety, and response duration results of nivolumab (anti-PD-1; BMS-936558; ONO- 4538) in a phase I trial in patients with previously treated metastatic renal cell carcinoma (mRCC): long-term patient follow-up.J Clin Oncol. 2013;31(suppl, abstr 4514).
9. Study of BMS-936558 vs everolimus in pretreated advanced or metastatic clear-cell RCC. Clinicaltrials.gov ID: NCT01668784.