An update on safety evaluation of immune-based combinations in patients with advanced renal cell carcinoma

ABSTRACT

Introduction

Significant advances have been made in the first-line therapy of metastatic renal cell carcinoma (mRCC) since the approval of immune-based combinations, including nivolumab plus ipilimumab or cabozantinib, and pembrolizumab plus axitinib or lenvatinib.

Areas covered

The aim of this review is to compare the different safety profiles of first-line immune-based combinations versus sunitinib across the four respective pivotal trials (CheckMate 214, CheckMate 9ER, KEYNOTE-426, and CLEAR), with a particular attention to patients’ health-related quality of life (HRQoL) assessment.

Expert opinion

The concurrent use of an immune-checkpoint inhibitor (ICI) with a tyrosine kinase inhibitor (TKI) as a first-line treatment strategy for mRCC has highlighted the unmet clinical need for prompt detection and consequently proper management of adverse events (AEs), both immune-related and TKI-induced. Overlapping AEs, such as hypertransaminasemia, are most challenging to manage, and evidence is still outlined from clinical practice. The specific patterns of toxicities of the approved first-line immune-based combinations, along with the impact of these interventions on patients’ HRQoL, demand a deeper consideration by physicians while choosing the appropriate treatment for each individual mRCC patient. Both safety profile and HRQoL evaluation could be exploited to guide the first-line treatment selection in this setting.

KEYWORDS:

• Adverse events
• immune checkpoint inhibitors
• immune-based combinations
• immune-related adverse events
• metastatic renal cell carcinoma
• patient-reported outcomes
• quality of life
• safety

Article highlights

• Among the many immune-based combinations available as the first-line therapies in mRCC, the safety profile of each combination could be considered by physicians for the treatment choice, along with its impact on patients’ HRQoL.

• Nivolumab/ipilimumab, nivolumab/cabozantinib, pembrolizumab/lenvatinib, and pembrolizumab/axitinib are four combination strategies that showed survival benefits and clinical activity in mRCC first-line treatment; no prospective studies directly compared them in terms of safety and toxicity.

• ICI/ICI and ICI/TKI combinations are generally well tolerated if compared to sunitinib monotherapy even though ICI/TKI showed a higher ≥ grade 3 adverse event rate.

• Adequate adverse event detection and management improve safety, prolong duration, and may optimize efficacy of immune-based combination regimens.

• HRQoL appeared to be overall maintained or also improved in mRCC patients treated with novel immune-based combinations when compared with sunitinib.

• Nivolumab/cabozantinib and pembrolizumab/lenvatinib significantly delayed a meaningful HRQoL deterioration, while a potential positive correlation between patient-reported outcomes and survival outcomes was shown for the nivolumab/ipilimumab regimen.

Declaration of interests

F Massari has received research support and/or honoraria from Astellas, BMS, Janssen, Ipsen, MSD, and Pfizer outside the submitted work. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One reviewer has disclosed: advisory board: BMS, Genentech, EMD Serono, Merck, Sanofi, Seattle Genetics/Astellas, AstraZeneca, Exelixis, Janssen, Bicycle Therapeutics, Pfizer, Gilead, Scholar Rock, G1 Therapeutics, Eli Lilly/Loxo Oncology, Infinity Pharmaceuticals, Lucence Health, IMV, Vial, Syapse, and Tempus; consultant/scientific advisory board (SAB): Suba Therapeutics, and Syapse; research support to institution: Sanofi (iaward), AstraZeneca, Gilead, Helsinn, Lucence, BMS, EMD Serono, and Jazz Therapeutics; speaker: BIO – INFORMAÇÃO BRASILEIRA DE ONCOLOGIA Ltda, OLE Forum (Mexico), Seagen, Gilead, Natera, Exelixis, and Janssen; data safety monitoring committee honorarium: Mereo; employment: spouse employed by Myriad; writing/editor fees: Uptodate, Cancer Expert Now, Editor of Elsevier Practice Update Bladder Cancer Center of Excellence. The remaining peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.