Practical Experience With Lenvatinib/Everolimus in RCC
Insights From: Martin H. Voss, MD, Memorial Sloan Kettering Cancer Center; Thomas Hutson, DO, PharmD, FACP, Baylor University Medical Center; Texas Oncology; James J. Hsieh, MD, PhD, Washington University School of Medicine
Thomas Hutson, DO, PharmD, FACP: My personal clinical experience utilizing the combination of lenvatinib and everolimus has been exceptional. I have used them in my own practice in patients who have been in the refractory setting—patients who have had 2, 3, or 4 lines of therapy, patients who were quite symptomatic from their cancer. We have started the therapy at the recommended starting dose—18 mg of lenvatinib and 5 mg of everolimus—and witnessed significant improvement in symptom control, in stabilization of their cancer. To put it bluntly, I’ve taken patients who were getting close to needing supportive and palliative care and allowed them to have a reprieve where they were able to take this therapy, regain some control of their symptoms, and go on fighting their cancer for 1 year to 1.5 years longer.
James J. Hsieh, MD, PhD: I think lenvatinib/everolimus is a very, very potent combination in terms of treating kidney cancer. Of course, when you’re starting with combining 2 different drugs, you are combining different toxicities, so it’s a little difficult to tolerate. But in our experience, if you get patients early with this combination, they don’t actually experience too much toxicity. The toxicities actually come when a patient has been exposed to many, many lines of treatment. When you start to treat them with a little more toxic combination, they cannot tolerate it because they have already been beaten up by so many different things. So, if you want to use it, you don’t want to use it for too late. I would prefer to use it as second-line or third-line. The reason I’m saying that is I have experience using this combination on several patients who are refractory to anything that you can imagine—immunotherapy, targeted therapy. But when I put them on this combination, it works for them. Of course, we are not curing them, but it actually works for them. So, actually, I think that in the past or in the anti-VEGF era, the treatment benefit was for 80% of patients. This kind of combination, I believe, will benefit 90% or more of patients.
Martin H. Voss, MD: My personal experience, outside clinical trials, in using lenvatinib/everolimus really reflects what we learned on the studies that led up to the approval of this regimen. I see a high level of activity for pretreated patients. I see many patients with significant tumor reductions on their scans. But I do confirm in my nonclinical trial practice that this is a challenging regimen and that patients and doctors have to work hard to get patients on tolerable dose levels and achieve long-term tumor control.