Goals in Relapsed/Refractory Metastatic RCC

All patients with metastatic renal cell carcinoma who receive first-line therapy will ultimately relapse, says Susanne Osanto, MD. It is difficult to know when to stop first-line treatment and continue with second-line therapy. In clinical practice, it is important to look at the amount of tumor burden, the aggressiveness of the disease, comorbidities, and whether there are new metastases.

Until recently, the goal of second-line treatment focused more on quality of life, because patients did not live long. With the emergence of data from newer trials, however, improvement in overall survival becomes a more realistic second-line goal, says Osanto. The large number of trials and therapeutic options makes the choice among second-line agents difficult. The RECORD-1 trial showed a clear advantage with using an mTOR inhibitor in the second line.

There are other studies that demonstrate the efficacy of following initial therapy with a TKI with a second TKI in the second line. There are two different settings to consider in second line, says Bernard Escudier, MD. If a patient has bulky disease and is symptomatic, the goal of second-line therapy should be to shrink the tumor. A good option for this is axitinib, he adds. If the patient is still relatively asymptomatic, the goal should be overall survival and quality of life. A better option for these patients may be everolimus, which has a favorable toxicity profile, Escudier says.