Dr. Agarwal on Frontline Treatment in Kidney Cancer

Neeraj Agarwal, MD, associate professor, Division of Oncology, Department of Medicine, University of Utah School of Medicine, Huntsman Cancer Institute, discusses his preferred frontline treatment for patients with kidney cancer.

In a randomized phase III trial, the combination of nivolumab (Opdivo) and ipilimumab (Yervoy) was superior to sunitinib (Sutent) in intermediate- and poor-risk patients with newly diagnosed metastatic renal cell carcinoma (RCC). There is stronger evidence favoring the combination in these patients, says Agarwal.

However, thorough evaluation of the data showed that favorable-risk patients experienced greater benefit with sunitinib. For those patients, Agarwal says that a VEGF tyrosine kinase inhibitor is the drug of choice. Since cabozantinib (Cabometyx) bested sunitinib in a randomized phase II trial, Agarwal recommends cabozantinib for this subgroup.

Most of the patients who had 1% or greater PD-L1 expression in the phase III trial derived the most benefit from the combination of nivolumab and ipilimumab. However, the majority of patients’ tumors in that trial did not have high PD-L1 expression. Therefore, in select patients whose tumors do not express PD-L1, Agarwal tends to favor cabozantinib.