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Agarwal Expands on Sequencing Options in mRCC

Caroline Seymour
Published: Wednesday, Jan 30, 2019

Neeraj Agarwal, MD

Neeraj Agarwal, MD
With more than 11 therapies FDA approved for patients with metastatic renal cell carcinoma (mRCC), sequencing therapies has become a challenge for many clinicians. For those who progress on frontline therapy, the most effective second-line therapy, according to Neeraj Agarwal, MD, is cabozantinib (Cabometyx).

State of the Science Summit™ on Genitourinary Cancers, Agarwal discussed his preferred sequencing strategies in the treatment of patients with mRCC.

OncLive®: How has mRCC treatment changed over the past decade?

Agarwal: It’s amazing to see how much has changed in the last 10 years. Just 10 years ago, all we had was interferon or high-dose interleukin therapy. Since the approval of sorafenib (Nexavar)—the first VEGF TKI to be approved for these patients—we have seen more than 10 agents get approved. We continue to see new approvals every 6 months now, [and it has become] very challenging [to figure] how to sequence these agents and how to maximize their efficacy so that we can improve the OS and quality of life for our patients.

What are some sequencing considerations?

I would divide these agents into 4 major classes. First, there are agents that target VEGF; these would be the VEGF TKIs or VEGF antibodies, such as sunitinib (Sutent), pazopanib (Votrient), sorafenib, or bevacizumab (Avastin). The second class is of the second-generation VEGF inhibitors, such as cabozantinib, which also have activity against other tyrosine kinases. Cabozantinib also inhibits AXL and cMET.  There is lenvatinib (Lenvima), which also inhibits FGFR, which is considered to be among the resistance mechanisms for VEGF blockade.
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