Richard W. Joseph, MD, internist and oncologist, Mayo Clinic, discusses the process of selecting frontline therapy in metastatic renal cell carcinoma (mRCC).
Favorable-risk patients tend to do very well with TKI monotherapy, says Joseph. For example, Joseph has had several patients who have been on a TKI for over 5 years. Despite the introduction of combinations of immunotherapy and VEGF TKIs, there remains a role for TKI monotherapy, specifically among favorable-risk patients with slow-growing disease or those who do not want the added toxicity that comes with combination therapy.
The newer combinations play a much bigger role in intermediate- and poor-risk patients, but they can also be used in favorable-risk patients. The decision is multifaceted, explains Joseph, but one of the most important considerations is patient preference. Younger, healthier patients may be willing to take on greater risk, whereas older patients may opt for a more conservative approach.
Joseph tends to favor the combination of 2 immunotherapy agents in intermediate- and poor-risk patients, so that he can turn to an anti-VEGF therapy upon disease progression. Moreover, the double immunotherapy combinations have shown a high rate of complete remissions, which may lead to durable responses and potential treatment discontinuation.