Dr Garmezy on Choosing an IO/TKI Treatment Regimen in ccRCC

Benjamin Garmezy, MD, medical oncologist, assistant director, Genitourinary Research, Sarah Cannon Research Institute, Tennessee Oncology, discusses in which scenarios he would choose an immuno-oncology (IO)/TKI regimen for the treatment of patients with clear cell renal cell carcinoma (ccRCC).

Deciding whether to use an IO/TKI regimen in an eligible patient with ccRCC can be challenging, he begins. Garmezy says he approaches this decision in a way that may differ from what an average community oncologist would do, given the volume of patients with RCC who receive care at specialty clinics vs in the community setting. If there are concerns about how a patient might respond to IO/TKI regimens and about distinguishing between toxicities associated with immunotherapy or the TKI, it could be prudent for oncologists to consider treatment with axitinib (Inlyta), Garmezy explains.

For instance, a patient with a history of rheumatologic issues in whom a checkpoint inhibitor may be contraindicated but who requires a durable response may benefit from treatment with pembrolizumab (Keytruda) plus axitinib, Garmezy continues. Patients may discontinue axitinib if they develop toxicity, enabling differentiation between immune-related and VEGF TKI–related adverse effects, he notes.

For younger patients ineligible for surgery who require a swift response, oncologists can administer pembrolizumab plus lenvatinib (Lenvima), provided they can tolerate lenvatinib at a dose of 20 mg, he expands, adding that the combination yields high response rates, likely due to the dosage of lenvatinib. It's noteworthy that this dose of lenvatinib differs significantly from the 40 mg dose of cabozantinib (Cabometyx) seen in other approved combinations for patients with RCC, Garmezy says.

Patients may also receive cabozantinib plus nivolumab (Opdivo), backed by quality-of-life data indicating that this combination is less toxic than sunitinib (Sutent), he explains. Cabozantinib plus nivolumab serves as the default regimen outside of the aforementioned options. Garmezy uses all 4 regimens relatively evenly.