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Aldin A, Besiroglu B, Adams A, Monsef I, Piechotta V, Tomlinson E, Hornbach C, Dressen N, Goldkuhle M, Maisch P, Dahm P, Heidenreich A, Skoetz N. First-line therapy for adults with advanced renal cell carcinoma: a systematic review and network meta-analysis. Cochrane Database Syst Rev 2023; 5:CD013798. [PMID: 37146227 PMCID: PMC10158799 DOI: 10.1002/14651858.cd013798.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Since the approval of tyrosine kinase inhibitors, angiogenesis inhibitors and immune checkpoint inhibitors, the treatment landscape for advanced renal cell carcinoma (RCC) has changed fundamentally. Today, combined therapies from different drug categories have a firm place in a complex first-line therapy. Due to the large number of drugs available, it is necessary to identify the most effective therapies, whilst considering their side effects and impact on quality of life (QoL). OBJECTIVES To evaluate and compare the benefits and harms of first-line therapies for adults with advanced RCC, and to produce a clinically relevant ranking of therapies. Secondary objectives were to maintain the currency of the evidence by conducting continuous update searches, using a living systematic review approach, and to incorporate data from clinical study reports (CSRs). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, conference proceedings and relevant trial registries up until 9 February 2022. We searched several data platforms to identify CSRs. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating at least one targeted therapy or immunotherapy for first-line treatment of adults with advanced RCC. We excluded trials evaluating only interleukin-2 versus interferon-alpha as well as trials with an adjuvant treatment setting. We also excluded trials with adults who received prior systemic anticancer therapy if more than 10% of participants were previously treated, or if data for untreated participants were not separately extractable. DATA COLLECTION AND ANALYSIS All necessary review steps (i.e. screening and study selection, data extraction, risk of bias and certainty assessments) were conducted independently by at least two review authors. Our outcomes were overall survival (OS), QoL, serious adverse events (SAEs), progression-free survival (PFS), adverse events (AEs), the number of participants who discontinued study treatment due to an AE, and the time to initiation of first subsequent therapy. Where possible, analyses were conducted for the different risk groups (favourable, intermediate, poor) according to the International Metastatic Renal-Cell Carcinoma Database Consortium Score (IMDC) or the Memorial Sloan Kettering Cancer Center (MSKCC) criteria. Our main comparator was sunitinib (SUN). A hazard ratio (HR) or risk ratio (RR) lower than 1.0 is in favour of the experimental arm. MAIN RESULTS We included 36 RCTs and 15,177 participants (11,061 males and 4116 females). Risk of bias was predominantly judged as being 'high' or 'some concerns' across most trials and outcomes. This was mainly due to a lack of information about the randomisation process, the blinding of outcome assessors, and methods for outcome measurements and analyses. Additionally, study protocols and statistical analysis plans were rarely available. Here we present the results for our primary outcomes OS, QoL, and SAEs, and for all risk groups combined for contemporary treatments: pembrolizumab + axitinib (PEM+AXI), avelumab + axitinib (AVE+AXI), nivolumab + cabozantinib (NIV+CAB), lenvatinib + pembrolizumab (LEN+PEM), nivolumab + ipilimumab (NIV+IPI), CAB, and pazopanib (PAZ). Results per risk group and results for our secondary outcomes are reported in the summary of findings tables and in the full text of this review. The evidence on other treatments and comparisons can also be found in the full text. Overall survival (OS) Across risk groups, PEM+AXI (HR 0.73, 95% confidence interval (CI) 0.50 to 1.07, moderate certainty) and NIV+IPI (HR 0.69, 95% CI 0.69 to 1.00, moderate certainty) probably improve OS, compared to SUN, respectively. LEN+PEM may improve OS (HR 0.66, 95% CI 0.42 to 1.03, low certainty), compared to SUN. There is probably little or no difference in OS between PAZ and SUN (HR 0.91, 95% CI 0.64 to 1.32, moderate certainty), and we are uncertain whether CAB improves OS when compared to SUN (HR 0.84, 95% CI 0.43 to 1.64, very low certainty). The median survival is 28 months when treated with SUN. Survival may improve to 43 months with LEN+PEM, and probably improves to: 41 months with NIV+IPI, 39 months with PEM+AXI, and 31 months with PAZ. We are uncertain whether survival improves to 34 months with CAB. Comparison data were not available for AVE+AXI and NIV+CAB. Quality of life (QoL) One RCT measured QoL using FACIT-F (score range 0 to 52; higher scores mean better QoL) and reported that the mean post-score was 9.00 points higher (9.86 lower to 27.86 higher, very low certainty) with PAZ than with SUN. Comparison data were not available for PEM+AXI, AVE+AXI, NIV+CAB, LEN+PEM, NIV+IPI, and CAB. Serious adverse events (SAEs) Across risk groups, PEM+AXI probably increases slightly the risk for SAEs (RR 1.29, 95% CI 0.90 to 1.85, moderate certainty) compared to SUN. LEN+PEM (RR 1.52, 95% CI 1.06 to 2.19, moderate certainty) and NIV+IPI (RR 1.40, 95% CI 1.00 to 1.97, moderate certainty) probably increase the risk for SAEs, compared to SUN, respectively. There is probably little or no difference in the risk for SAEs between PAZ and SUN (RR 0.99, 95% CI 0.75 to 1.31, moderate certainty). We are uncertain whether CAB reduces or increases the risk for SAEs (RR 0.92, 95% CI 0.60 to 1.43, very low certainty) when compared to SUN. People have a mean risk of 40% for experiencing SAEs when treated with SUN. The risk increases probably to: 61% with LEN+PEM, 57% with NIV+IPI, and 52% with PEM+AXI. It probably remains at 40% with PAZ. We are uncertain whether the risk reduces to 37% with CAB. Comparison data were not available for AVE+AXI and NIV+CAB. AUTHORS' CONCLUSIONS Findings concerning the main treatments of interest comes from direct evidence of one trial only, thus results should be interpreted with caution. More trials are needed where these interventions and combinations are compared head-to-head, rather than just to SUN. Moreover, assessing the effect of immunotherapies and targeted therapies on different subgroups is essential and studies should focus on assessing and reporting relevant subgroup data. The evidence in this review mostly applies to advanced clear cell RCC.
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Affiliation(s)
- Angela Aldin
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Burcu Besiroglu
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anne Adams
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Eve Tomlinson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Carolin Hornbach
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nadine Dressen
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Marius Goldkuhle
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Philipp Dahm
- Urology Section, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Axel Heidenreich
- Department of Urology, Uro-oncology, Special Urological and Robot-assisted Surgery, University Hospital of Cologne, Cologne, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Latest progress in molecular biology and treatment in genitourinary tumours. Clin Transl Oncol 2020; 22:2175-2195. [PMID: 32440915 DOI: 10.1007/s12094-020-02373-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/01/2020] [Indexed: 12/24/2022]
Abstract
The management of genitourinary cancer, including bladder, prostate, renal and testicular cancer, has evolved dramatically in recent years due to a better understanding of tumour genetic mutations, alterations in molecular pathways, and to the development of new kinds of drugs such as targeted therapies and immunotherapies. In the field of immunotherapy, new drugs focused on stimulating, enhancing and modulating the immune system to detect and destroy cancer, have been recently discovered. Research in oncology moves quickly and new data of great relevance for clinical practice are communicated every year. For this reason, a group of experts, focused exclusively on the treatment of genitourinary tumours and who get together every year in the BestGU conference to assess the latest progress in this field have summarized the most important advances in a single review, along with a critical assessment of whether these results should alter daily clinical practice.
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Hegde PS, Chen DS. Top 10 Challenges in Cancer Immunotherapy. Immunity 2020; 52:17-35. [PMID: 31940268 DOI: 10.1016/j.immuni.2019.12.011] [Citation(s) in RCA: 1095] [Impact Index Per Article: 273.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 11/01/2019] [Accepted: 12/14/2019] [Indexed: 02/08/2023]
Abstract
Cancer immunotherapy is a validated and critically important approach for treating patients with cancer. Given the vast research and clinical investigation efforts dedicated to advancing both endogenous and synthetic immunotherapy approaches, there is a need to focus on crucial questions and define roadblocks to the basic understanding and clinical progress. Here, we define ten key challenges facing cancer immunotherapy, which range from lack of confidence in translating pre-clinical findings to identifying optimal combinations of immune-based therapies for any given patient. Addressing these challenges will require the combined efforts of basic researchers and clinicians, and the focusing of resources to accelerate understanding of the complex interactions between cancer and the immune system and the development of improved treatment options for patients with cancer.
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Ascierto PA, Bifulco C, Buonaguro L, Emens LA, Ferris RL, Fox BA, Delgoffe GM, Galon J, Gridelli C, Merlano M, Nathan P, Odunsi K, Okada H, Paulos CM, Pignata S, Schalper KA, Spranger S, Tortora G, Zarour H, Butterfield LH, Puzanov I. Perspectives in immunotherapy: meeting report from the "Immunotherapy Bridge 2018" (28-29 November, 2018, Naples, Italy). J Immunother Cancer 2019; 7:332. [PMID: 31783779 PMCID: PMC6884742 DOI: 10.1186/s40425-019-0798-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 10/30/2019] [Indexed: 12/12/2022] Open
Abstract
Immunotherapy is now widely established as a potent and effective treatment option across several types of cancer. However, there is increasing recognition that not all patients respond to immunotherapy, focusing attention on the immune contexture of the tumor microenvironment (TME), drivers of the immune response and mechanisms of tumor resistance to immunity. The development of novel immunotherapeutics and their use in combination with checkpoint inhibitors and other standard of care and novel treatment modalities is an area of particular attention across several tumor types, including melanoma, lung, ovarian, breast, pancreatic, renal, head and neck, brain and non-melanoma skin cancers. The 4th Immunotherapy Bridge meeting (28-29 November, 2018, Naples, Italy) focused on a wide range of evolving topics and trends in the field of cancer immunotherapy and key presentations from this meeting are summarised in this report.
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Affiliation(s)
- Paolo A Ascierto
- Unit of Medical Oncology and Innovative Therapy, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Via Mariano Semmola, 80131, Naples, Italy.
| | - Carlo Bifulco
- Earle A. Chiles Research Institute, Robert W. Franz Cancer Research Center, Providence Portland Medical Center, Portland, OR, USA
| | - Luigi Buonaguro
- Cancer Immunoregulation Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, Naples, Italy
| | - Leisha A Emens
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert L Ferris
- UPMC Hillman Cancer Center, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bernard A Fox
- Laboratory of Molecular and Tumor Immunology, Robert W. Franz Cancer Center in the Earle A. Chiles Research Institute at Providence Cancer Institute, Portland, Oregon, USA
| | - Greg M Delgoffe
- Department of Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jérôme Galon
- National Institute of Health and Medical Research, INSERM, Cordeliers Research Center, Paris, France
| | - Cesare Gridelli
- Unit of Medical Oncology, Hospital "San Giuseppe Moscati", Avellino, Italy
| | - Marco Merlano
- Oncology Department, ASO Santa Croce e Carle Cuneo, Cuneo, Italy
| | - Paul Nathan
- Mount Vernon Cancer Centre, Northwood, Middlesex, UK
| | - Kunle Odunsi
- Department of Gynaecologic Oncology, Executive Director, Center for Immunotherapy, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Hideho Okada
- Department of Neurological Surgery, University of California San Francisco, Parker Institute for Cancer Immunotherapy, San Francisco, California, USA
| | - Chrystal M Paulos
- Department of Microbiology and Immunology Hollings Cancer Center, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Sandro Pignata
- Uro-Gynaecological Department, Istituto Nazionale Tumori Fondazione G. Pascale, IRCCS, Naples, Italy
| | - Kurt A Schalper
- Department of Pathology, Yale School of Medicine, Translational Immuno-oncology Laboratory, Yale Cancer Center, Medical Oncology, Yale School of Medicine and Yale Cancer Center, New Haven, CT, USA
| | - Stefani Spranger
- The Koch Institute for Integrative Cancer Research at MIT and Department of Biology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Giampaolo Tortora
- Medical Oncology, Fondazione Policlinico Universitario Gemelli, IRCCS, Rome, Italy
| | - Hassane Zarour
- Melanoma Program, University of Pittsburgh Cancer Institute, Pittsburgh, PA, USA
| | - Lisa H Butterfield
- Parker Institute for Cancer Immunotherapy Research Center, UCSF, San Francisco, California, USA.
| | - Igor Puzanov
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
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Stühler V, Maas JM, Rausch S, Stenzl A, Bedke J. Immune checkpoint inhibition for the treatment of renal cell carcinoma. Expert Opin Biol Ther 2019; 20:83-94. [PMID: 31587590 DOI: 10.1080/14712598.2020.1677601] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Introduction: The systemic therapy in metastatic renal cell carcinoma (mRCC) is moving from tyrosine kinase inhibitors (TKIs) and mammalian target of rapamycin (mTOR) inhibitors to immune checkpoint inhibitors and its combination with TKIs.Areas covered: This review provides a general overview using immune checkpoint inhibition for the treatment of RCC. Clinical results from conducted and ongoing clinical trials are summarized and checkpoint inhibition is reviewed in the context to other available systemic therapies such as TKIs for mRCC based on the different International Metastastic RCC Database Consortium (IMCD) risk groups. Furthermore, prospects for the use of predictive biomarkers in the decision-making process of chosen therapy will be given.Expert opinion: Using checkpoint inhibition in mRCC has demonstrated a superior efficacy for patients with IMDC intermediate and poor risk for ipilimumab combined with nivolumab. Furthermore, therapeutic regimes with tyrosine kinase inhibition plus immune checkpoint-inhibition were recently presented and demonstrated superiority in all risk groups for axitinib plus pembrolizumab in overall survival and progression-free survival (PFS) and axitinib plus avelumab in PFS compared to sunitinib monotherapy. Novel biomarkers of response to further optimize therapeutic selection and patient outcomes are ongoing medical objectives.
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Affiliation(s)
- Viktoria Stühler
- Department of Urology, University of Tübingen, Tübingen, Germany
| | - Jan Moritz Maas
- Department of Urology, University of Tübingen, Tübingen, Germany
| | - Steffen Rausch
- Department of Urology, University of Tübingen, Tübingen, Germany
| | - Arnulf Stenzl
- Department of Urology, University of Tübingen, Tübingen, Germany
| | - Jens Bedke
- Department of Urology, University of Tübingen, Tübingen, Germany
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Soares A, Maia MC, Vidigal F, Marques Monteiro FS. Cytoreductive Nephrectomy for Metastatic Renal Cell Carcinoma: How to Apply New Evidence in Clinical Practice. Oncology 2019; 98:1-9. [PMID: 31514196 DOI: 10.1159/000502778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/07/2019] [Indexed: 11/19/2022]
Abstract
Cytoreductive nephrectomy (CN) followed by systemic therapy had been considered the standard of care for metastatic renal cell carcinoma (mRCC) patients since two clinical trials established its role during the cytokines era. With introduction of new and effective drugs, such as vascular endothelial growth factor-targeted therapies, the role of CN started to be challenged. Retrospective studies conducted during the targeted therapy era pointed to better outcomes when CN was associated with systemic treatment, although certain patients with poor risk features did not seem to benefit. Therefore, prospective clinical trials supporting CN were needed. Recently, with the publication of two randomized trials evaluating CN in the targeted therapy era, it has been made clear that patient selection and multidisciplinary discussion are of paramount importance in order to achieve the best outcomes. We reviewed the available literature on the role of CN among mRCC patients, commenting on how to apply the new evidence into clinical practice and providing future perspectives.
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Affiliation(s)
- Andrey Soares
- Department of Medical Oncology, Hospital Israelita Albert Einstein, São Paulo, Brazil, .,Department of Medical Oncology, Centro Paulista de Oncologia, São Paulo, Brazil, .,Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil,
| | - Manuel C Maia
- Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil.,Department of Medical Oncology, Centro de Oncologia do Paraná, Curtiba, Brazil
| | - Fernando Vidigal
- Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil.,Department of Medical Oncology, Hospital Sírio Libanês - Unidade Brasília, Brasília, Brazil
| | - Fernando Sabino Marques Monteiro
- Latin American Cooperative Oncology Group Genitourinary Group, Porto Alegre, Brazil.,Hospital Santa Lúcia, Brasília, Brazil.,Hospital Universitário de Brasília, Universidade Nacional de Brasília, Brasília, Brazil
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Nizam A, Rhea LP, Gupta B, Aragon-Ching JB. The Emerging Role of Combination Angiogenesis Inhibitors and Immune Checkpoint Inhibitors in the Treatment of Metastatic Renal Cell Cancer. KIDNEY CANCER 2019. [DOI: 10.3233/kca-190050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Amanda Nizam
- Department of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Logan P. Rhea
- Department of Medicine, Inova Fairfax Hospital, Fairfax, VA, USA
| | - Brinda Gupta
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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Chang SL, Choueiri TK, Harshman LC. Does CARMENA mark the end of cytoreductive nephrectomy for metastatic renal cell carcinoma? Urol Oncol 2019. [DOI: 10.1016/j.urolonc.2019.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rini BI, Powles T, Atkins MB, Escudier B, McDermott DF, Suarez C, Bracarda S, Stadler WM, Donskov F, Lee JL, Hawkins R, Ravaud A, Alekseev B, Staehler M, Uemura M, De Giorgi U, Mellado B, Porta C, Melichar B, Gurney H, Bedke J, Choueiri TK, Parnis F, Khaznadar T, Thobhani A, Li S, Piault-Louis E, Frantz G, Huseni M, Schiff C, Green MC, Motzer RJ. Atezolizumab plus bevacizumab versus sunitinib in patients with previously untreated metastatic renal cell carcinoma (IMmotion151): a multicentre, open-label, phase 3, randomised controlled trial. Lancet 2019; 393:2404-2415. [PMID: 31079938 DOI: 10.1016/s0140-6736(19)30723-8] [Citation(s) in RCA: 723] [Impact Index Per Article: 144.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 03/01/2019] [Accepted: 03/12/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND A phase 2 trial showed improved progression-free survival for atezolizumab plus bevacizumab versus sunitinib in patients with metastatic renal cell carcinoma who express programmed death-ligand 1 (PD-L1). Here, we report results of IMmotion151, a phase 3 trial comparing atezolizumab plus bevacizumab versus sunitinib in first-line metastatic renal cell carcinoma. METHODS In this multicentre, open-label, phase 3, randomised controlled trial, patients with a component of clear cell or sarcomatoid histology and who were previously untreated, were recruited from 152 academic medical centres and community oncology practices in 21 countries, mainly in Europe, North America, and the Asia-Pacific region, and were randomly assigned 1:1 to either atezolizumab 1200 mg plus bevacizumab 15 mg/kg intravenously once every 3 weeks or sunitinib 50 mg orally once daily for 4 weeks on, 2 weeks off. A permuted-block randomisation (block size of 4) was applied to obtain a balanced assignment to each treatment group with respect to the stratification factors. Study investigators and participants were not masked to treatment allocation. Patients, investigators, independent radiology committee members, and the sponsor were masked to PD-L1 expression status. Co-primary endpoints were investigator-assessed progression-free survival in the PD-L1 positive population and overall survival in the intention-to-treat (ITT) population. This trial is registered with ClinicalTrials.gov, number NCT02420821. FINDINGS Of 915 patients enrolled between May 20, 2015, and Oct 12, 2016, 454 were randomly assigned to the atezolizumab plus bevacizumab group and 461 to the sunitinib group. 362 (40%) of 915 patients had PD-L1 positive disease. Median follow-up was 15 months at the primary progression-free survival analysis and 24 months at the overall survival interim analysis. In the PD-L1 positive population, the median progression-free survival was 11·2 months in the atezolizumab plus bevacizumab group versus 7·7 months in the sunitinib group (hazard ratio [HR] 0·74 [95% CI 0·57-0·96]; p=0·0217). In the ITT population, median overall survival had an HR of 0·93 (0·76-1·14) and the results did not cross the significance boundary at the interim analysis. 182 (40%) of 451 patients in the atezolizumab plus bevacizumab group and 240 (54%) of 446 patients in the sunitinib group had treatment-related grade 3-4 adverse events: 24 (5%) in the atezolizumab plus bevacizumab group and 37 (8%) in the sunitinib group had treatment-related all-grade adverse events, which led to treatment-regimen discontinuation. INTERPRETATION Atezolizumab plus bevacizumab prolonged progression-free survival versus sunitinib in patients with metastatic renal cell carcinoma and showed a favourable safety profile. Longer-term follow-up is necessary to establish whether a survival benefit will emerge. These study results support atezolizumab plus bevacizumab as a first-line treatment option for selected patients with advanced renal cell carcinoma. FUNDING F Hoffmann-La Roche Ltd and Genentech Inc.
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Affiliation(s)
- Brian I Rini
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Thomas Powles
- Barts Cancer Institute and the Royal Free Hospital, Queen Mary University of London, London, UK
| | - Michael B Atkins
- Georgetown Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | | | | | - Cristina Suarez
- Vall d'Hebron Institute of Oncology, Vall d'Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Frede Donskov
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark
| | - Jae Lyun Lee
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Alain Ravaud
- CHU Hôpitaux de Bordeaux-Hôpital Saint-André, Bordeaux, France
| | | | - Michael Staehler
- Klinikum der Universität München, Campus Großhadern, München, Germany
| | - Motohide Uemura
- Department of Urology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ugo De Giorgi
- Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori, IRCCS, Meldola, Italy
| | - Begoña Mellado
- Hospital Clínic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
| | - Camillo Porta
- IRCCS San Matteo University Hospital Foundation, Pavia, Italy
| | - Bohuslav Melichar
- Lékařská Fakulta Univerzita Palackého a Fakultní Nemocnice Olomouc, Olomouc, Czech Republic
| | - Howard Gurney
- Department of Clinical Medicine, Macquarie University, Sydney, NSW, Australia
| | - Jens Bedke
- Department of Urology, University of Tübingen, Tübingen, Germany
| | | | - Francis Parnis
- Ashford Cancer Centre Research, Kurralta Park, SA, Australia
| | | | | | - Shi Li
- Genentech, Inc, South San Francisco, CA, USA
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García-Aranda M, Redondo M. Targeting Protein Kinases to Enhance the Response to anti-PD-1/PD-L1 Immunotherapy. Int J Mol Sci 2019; 20:E2296. [PMID: 31075880 PMCID: PMC6540309 DOI: 10.3390/ijms20092296] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 05/06/2019] [Accepted: 05/07/2019] [Indexed: 12/11/2022] Open
Abstract
The interaction between programmed cell death protein (PD-1) and its ligand (PD-L1) is one of the main pathways used by some tumors to escape the immune response. In recent years, immunotherapies based on the use of antibodies against PD-1/PD-L1 have been postulated as a great promise for cancer treatment, increasing total survival compared to standard therapy in different tumors. Despite the hopefulness of these results, a significant percentage of patients do not respond to such therapy or will end up evolving toward a progressive disease. Besides their role in PD-L1 expression, altered protein kinases in tumor cells can limit the effectiveness of PD-1/PD-L1 blocking therapies at different levels. In this review, we describe the role of kinases that appear most frequently altered in tumor cells and that can be an impediment for the success of immunotherapies as well as the potential utility of protein kinase inhibitors to enhance the response to such treatments.
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Affiliation(s)
- Marilina García-Aranda
- Research Unit, Hospital Costa del Sol. Autovía A7, km 187. Marbella, 29603 Málaga, Spain.
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), 28029 Madrid, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain.
| | - Maximino Redondo
- Research Unit, Hospital Costa del Sol. Autovía A7, km 187. Marbella, 29603 Málaga, Spain.
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), 28029 Madrid, Spain.
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain.
- Departamento de Especialidades Quirúrgicas, Bioquímica e Inmunología, Universidad de Málaga, Campus Universitario de Teatinos, 29010 Málaga, Spain.
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The Changing Landscape of Management of Metastatic Renal Cell Carcinoma: Current Treatment Options and Future Directions. Curr Treat Options Oncol 2019; 20:41. [PMID: 30937639 DOI: 10.1007/s11864-019-0638-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT For the practicing clinician, the dilemma becomes how most appropriate to sequence the aforementioned regimens. It is challenging to be dogmatic, as there are no comparative studies juxtaposing novel front-line options directly-all of the available studies utilize a comparator arm of sunitinib. With this in mind, the selection of front-line therapy with a patient with mRCC should involve a thorough discussion of both efficacy and safety of available options. The oncologist must also weigh their ability to manage complex immune-related adverse events that can emerge from checkpoint inhibitors, particularly with dual regimens such as nivolumab/ipilimumab. For the patient with good-risk disease, VEGF-directed therapies should remain a component of treatment. The data from CheckMate-214 does not support the use of nivolumab/ipilimumab in this setting, and in fact suggests superiority with the approach of VEGF-TKIs. Until regulatory decisions have been made around bevacizumab/atezolizumab and axitinib/avelumab, sunitinib and pazopanib remain options for patients with good-risk disease, although cabozantinib should be a consideration as well. Although the CABOSUN study did not include patients with good-risk disease, it is important to bear in mind that this was more of a pragmatic decision-inclusion of these patients in the original design could have potentially lengthened the extent of necessary follow-up. From a mechanistic standpoint, there is no reason to assume that cabozantinib would not also achieve superiority to sunitinib in patients with good-risk disease. For patients with intermediate- and poor-risk disease, cabozantinib and nivolumab/ipilimumab represent the only reasonable options thus far that have achieved regulatory approval. As previously noted, nivolumab/ipilimumab has proven benefit in this setting, but should be used only by the oncologist who has ready access to subspecialists who can aid in managing immune-related adverse events. Prompt recognition of colitis, hepatitis, and other sequelae from these therapies is critical, as these toxicities can be life-threatening. If such resources are not available, then cabozantinib should be considered. Cabozantinib should further be contemplated in the subset of patients with bony metastatic disease, where it appears to offer substantial control. Of course, it also represents an option for those individuals who have contraindications to immunotherapy, such as rheumatologic and autoimmune disorders.When combinations of VEGF-directed and immunotherapies are approved, the clinician will have an even more complicated dilemma. Regimens such as a bevacizumab/atezolizumab offer an exceptional safety profile, which may weigh heavily in frail patients who cannot tolerate the side effect profile associated with VEGF-TKIs.
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Canino C, Perrone L, Bosco E, Saltalamacchia G, Mosca A, Rizzo M, Porta C. Targeting angiogenesis in metastatic renal cell carcinoma. Expert Rev Anticancer Ther 2019; 19:245-257. [PMID: 30678509 DOI: 10.1080/14737140.2019.1574574] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Renal cell carcinoma (RCC), and particularly its clear cell histological subtype, is commonly characterized by genetic alterations in the Von Hippel Lindau (VHL) tumor suppressor gene, leading to a typically exasperated angiogenesis. However, other biological and genetic peculiarities contribute to differentiate this malignancy from other solid tumors, including its immunogenicity. Areas covered: This review focuses on the present and future role of antiangiogenic drugs, administered either alone (as it has been in the past few years), or in combination with other agents (e.g. immune checkpoint inhibitors), in the treatment of metastatic RCC. Expert commentary: Due to its peculiar pathogenesis, it is unrealistic to expect to be able to get rid of antiangiogenic agents for the treatment of this disease; however, we do expect that combinations of VEGF/VEGFRs-targeting agents with immune checkpoint inhibitors will gradually replace antiangiogenic monotherapies as the standard of care, at least in the first line setting of metastatic RCC patients. Biomarkers discovery remains the highest priority in order to further improve the percentage of patients benefitting of our treatment.
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Affiliation(s)
- Costanza Canino
- a Division of Translational Oncology , I.R.C.C.S. Istituti Clinici Scientifici Maugeri , Pavia , Italy
| | - Lorenzo Perrone
- b Division of Oncology , I.R.C.C.S. Istituti Clinici Scientifici Maugeri , Pavia , Italy
| | - Eugenia Bosco
- a Division of Translational Oncology , I.R.C.C.S. Istituti Clinici Scientifici Maugeri , Pavia , Italy
| | - Giuseppe Saltalamacchia
- a Division of Translational Oncology , I.R.C.C.S. Istituti Clinici Scientifici Maugeri , Pavia , Italy
| | - Alessandra Mosca
- c Medical Oncology , Ospedale Maggiore della Carità , Novara , Italy
| | - Mimma Rizzo
- a Division of Translational Oncology , I.R.C.C.S. Istituti Clinici Scientifici Maugeri , Pavia , Italy
| | - Camillo Porta
- a Division of Translational Oncology , I.R.C.C.S. Istituti Clinici Scientifici Maugeri , Pavia , Italy.,d Department of Internal Medicine , University of Pavia , Pavia , Italy
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Amin A, Hammers H. The Evolving Landscape of Immunotherapy-Based Combinations for Frontline Treatment of Advanced Renal Cell Carcinoma. Front Immunol 2019; 9:3120. [PMID: 30687324 PMCID: PMC6335326 DOI: 10.3389/fimmu.2018.03120] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/18/2018] [Indexed: 12/25/2022] Open
Abstract
Insights into the biology of advanced renal cell carcinoma (aRCC) and the development of agents targeting the vascular endothelial growth factor (VEGF) pathway have positively impacted the outcomes for patients with aRCC. With the recent approval of the dual immune checkpoint inhibitors (ICIs), nivolumab and ipilimumab, by the U.S. Food and Drug Administration (USFDA), and the European Medicines Agency (EMA), the era of VEGF monotherapy for untreated aRCC appears to be coming to an end for patients with access to the combination therapy. The frontline treatment options for renal cell carcinoma are evolving rapidly and will lead to the approval of other combination immunotherapies-especially those with VEGF inhibitors. Here we review the clinical data for dual immune checkpoint inhibition with nivolumab plus ipilimumab as well as the emerging data for ICI plus VEGF inhibitor combinations and discuss the challenges these will pose for the clinical practitioner.
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Affiliation(s)
- Asim Amin
- Levine Cancer Institute, Charlotte, NC, United States
- Atrium Healthcare System, Charlotte, NC, United States
| | - Hans Hammers
- University of Texas Southwestern Medical Center, Dallas, TX, United States
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Stitzlein L, Rao PSS, Dudley R. Emerging oral VEGF inhibitors for the treatment of renal cell carcinoma. Expert Opin Investig Drugs 2018; 28:121-130. [DOI: 10.1080/13543784.2019.1559296] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Lea Stitzlein
- Department of Pharmaceutical Sciences, College of Pharmacy, The University of Findlay, Findlay, OH, USA
| | - PSS Rao
- Department of Pharmaceutical Sciences, College of Pharmacy, The University of Findlay, Findlay, OH, USA
| | - Richard Dudley
- Department of Pharmaceutical Sciences, College of Pharmacy, The University of Findlay, Findlay, OH, USA
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Chopra M. Annual Congress of the European Society for Medical Oncology (ESMO): Munich, Germany, 19-23 October 2018. Target Oncol 2018; 13:673-677. [PMID: 30426327 DOI: 10.1007/s11523-018-0608-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Martin Chopra
- Springer, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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