Two Lenvatinib Combos Induce Survival Benefit Over Sunitinib in Advanced RCC

Robert Motzer, MD

Findings from the phase 3 CLEAR trial (NCT02811861) showed that the addition of lenvatinib (Lenvima) to either pembrolizumab (Keytruda) or everolimus (Afinitor) led to an improvement in survival and response rates in comparison with sunitinib (Sutent) monotherapy in the first-line setting for patients with advanced renal cell carcinoma (RCC).^1,2

The results from the trial were presented during the 2021 Genitourinary Cancers Symposium and simultaneously published in The New England Journal of Medicine.

Previously, single-agent lenvatinib and pembrolizumab have been shown to be effective in treating RCC. The combination of lenvatinib and everolimus has also been shown to induce longer PFS than single-agent everolimus as a second-line treatment option. And, as Robert J. Motzer, MD, noted, results of a recent phase 1b/2 study of lenvatinib plus pembrolizumab showed anti-tumor activity in previously treated patients with RCC.

As a result, researchers aimed to assess the safety and efficacy of lenvatinib plus pembrolizumab, as well as lenvatinib plus everolimus, versus sunitinib alone in the first-line treatment of advanced RCC.

Motzer, the Kidney Cancer Section Head, Genitourinary Oncology Service; and Jack and Dorothy Byrne Chair in Clinical Oncology at Memorial Sloan Kettering Cancer Center, presented the results of the multi-center, open-label trial during the meeting.

Patients were eligible to enroll onto the trial if they were treatment-naïve, had adequate organ function, measurable disease and presented with advanced clear-cell RCC. Patients were then stratified into 2 geographic regions — Western Europe and North America vs. rest of the world — and stratified by favorable, intermediate or poor disease risk.

The trial comprised 1069 patients who were then randomized in a 1:1:1 fashion to receive lenvatinib 20 mg oral QD plus pembrolizumab 200 mg IV Q3W (n = 355), lenvatinib 18 mg oral QD plus everolimus 5 mg oral QD (n = 357), or sunitinib 50 mg oral QD for 4 weeks on and 2 weeks off (n = 357).

PFS by IRC per RECIST v1.1 was the primary endpoint, and secondary endpoints included OS, ORR by IRC per RECIST v1.1, safety and health-related quality of life (HRQoL).

The median PFS with lenvatinib and pembrolizumab was 23.9 months (95% CI, 20.8-27.7) compared to 9.2 months (95% CI, 6-11) with single-agent sunitinib (HR, 0.39; 95% CI, 0.32-0.49; P < .001). The lenvatinib plus everolimus treatment arm achieved a median PFS of 14.7 months (95% CI, 11.1-16.7) compared to the 9.2 months in the sunitinib arm (HR, 0.65; 95% CI, 0.53-0.8; P < .001).

The PFS benefit extended across all patient subgroups in both the lenvatinib and pembrolizumab and lenvatinib and everolimus treatment arms.

A median OS was not reached in any of the three treatment arms; however, the data indicated the endpoint was significantly longer in the lenvatinib and pembrolizumab arm compared to the sunitinib arm (HR, 0.66; 95% CI, 0.49-0.88; P = .005). Motzer noted that there was no observed OS benefit in the lenvatinib and everolimus treatment arm over sunitinib alone (HR, 1.15; 95% CI, 0.88-1.5; P = .3).

ORR was higher in both the lenvatinib plus pembrolizumab (71%; 95% CI, 66.3-75.7) and lenvatinib plus everolimus (53.5%; 95% CI, 48.3-58.7) treatment arms compared to sunitinib (36.1%; 95% CI, 31.2-41.1). Of note, Motzer mentioned the “high complete response rate” of 16.1% in the lenvatinib plus pembrolizumab arm.

Patients in the lenvatinib plus pembrolizumab arm achieved the longest median DOR at 25.8 months (95% CI, 22.1-27.9), compared to 16.6 months (95% CI, 14.6-20.6) in the lenvatinib plus everolimus arm and 14.6 months (95% CI, 9.4-16.7) in the sunitinib arm.

Nearly all patients in each treatment arm – lenvatinib plus pembrolizumab (96.9%), lenvatinib plus everolimus (97.7%) and sunitinib (92.1%) – experienced any treatment-related adverse event (TRAE). Patients in the lenvatinib plus pembrolizumab (67.3%) and lenvatinib plus everolimus (69.3%) treatment arms were more likely than the sunitinib arm (49.7%) to experience TRAEs that led to dose reductions. Of note, Motzer highlighted that the number of patients needing to have lenvatinib discontinued in either treatment arm was 18.5% and 16.1%, respectively. Moreover, the discontinuation rate of both drugs in the lenvatinib plus pembrolizumab arm was 9.7%.

Motzer noted the safety profiles of both combinations were consistent with each drugs’ known safety profile and were manageable as needed for dose modifications.

“These results support lenvatinib plus pembrolizumab as a potential first-line treatment for patients with advanced RCC,” he concluded.

_References

_{Motzer RJ, Porta C, Eto M, et al. Phase 3 trial of lenvatinib (LEN) plus pembrolizumab (PEMBRO) or everolimus (EVE) versus sunitinib (SUN) monotherapy as a first-line treatment for patients (pts) with advanced renal cell carcinoma (RCC) (CLEAR study). J Clin Oncol. 2021; 39(suppl6):269. doi: 10.1200/JCO.2021.39.6_suppl.269.}

_{Motzer RJ, Alekseev B, Rha S.-Y., et al. Lenvatinib plus Pembrolizumab or Everolimus for Advanced Renal Cell Carcinoma. Published online February 13, 2021. N Engl J Med. doi: 10.1056/NEJMoa2035716.}