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Evaluation of Provider Preferences in First-Line Metastatic Renal Cell Carcinoma: Comparison Between Dual Immunotherapy vs. Immunotherapy/Tyrosine Kinase Inhibitors

      Key Take Home Messages

      • Over the past few years, multiple new options have emerged for the treatment of patients with intermediate/poor-risk metastatic metastatic renal cell carcinoma (RCC), specifically ipilimumab/nivolumab (IO/IO) and multiple immunotherapy/tyrosine kinase inhibitor (IO/TKI) combinations (e.g. pembrolizumab/axitinib, nivolumab/cabozantinib). There have been no validated biomarkers, or a phase III trial, to guide selection between IO/IO vs. IO/TKI.
      • We performed an electronic survey-based study to evaluate whether oncologists prefer IO/IO vs. IO/TKI for patients with intermediate/poor-risk metastatic RCC and what factors go into their decision-making.
      • We sent 294 surveys and received 105 responses (36% response rate). 61% of providers chose IO/IO, 39% chose IO/TKI. 78% of oncologists were academic or disease-focused, 22% were general. Academic/GU-focused oncologists were significantly more likely to choose IO/IO (56/82, 68%) compared to general oncologists (8/23, 35%), P = .004.
      • The majority of oncologists noted toxicity to play a role in their decision-making. Despite the significant treatment preference among academic/GU oncologists, the majority of respondents felt comfortable enrolling patients into a phase III trial comparing IO/IO vs. IO/TKI, demonstrating continued equipoise surrounding this question in the community.

      Abstract

      Introduction

      Dual immunotherapy (ipilimumab/nivolumab, IO/IO) and immunotherapy/tyrosine kinase inhibitor (IO/TKI) combinations (e.g. pembrolizumab/axitinib) are approved for the first-line treatment of intermediate/poor risk metastatic renal cell carcinoma (RCC), but there is limited comparative data between these two options. We sought to understand how oncologists decide between IO/IO vs. IO/TKI.

      Methods

      We sent a 10-question electronic survey centered on a patient scenario of intermediate/poor risk metastatic RCC to 294 academic/disease-focused and general oncologists in the US.

      Results

      We received 105 responses (36% response rate): 61% (64) of providers chose IO/IO, 39% (41) chose IO/TKI. 78% (82) of oncologists were academic or disease-focused, 22% (23) were general. Academic/disease-focused oncologists were significantly more likely to choose IO/IO (56/82, 68%) than general oncologists (8/23, 35%), P = .004.
      Among those who chose IO/IO, the perceived main issue with IO/TKI was: long-term toxicities - 31% (20), short-term toxicities - 28% (18), less effective - 28% (18), less convenient - 8% (5). Among those who chose IO/TKI, the perceived main issue with IO/IO was: short-term toxicities - 43% (17), less effective - 28% (11), long-term toxicities - 15% (6), and risk of death - 10% (4).
      88% (92) of providers would be comfortable enrolling patients into a phase III trial comparing IO/IO vs. IO/TKI. We found no associations between therapy chosen by a provider and participation as PI in a trial of IO/IO or IO/TKI, or receipt of outside funding from an IO/IO or IO/TKI company.

      Conclusion

      In response to a patient scenario of intermediate/poor risk metastatic RCC, 61% of providers chose IO/IO, 39% chose IO/TKI. There was a significant association between type of practice and choice of therapy, with academic/disease-focused oncologists more likely to choose IO/IO. The majority of oncologists would be comfortable enrolling patients into a phase III trial comparing IO/IO vs. IO/TKI.

      Keywords

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      References

        • Motzer RJ
        • Tannir NM
        • McDermott DF
        • et al.
        Nivolumab plus ipilimumab versus sunitinib in advanced renal-cell carcinoma.
        N Engl J Med. 2018;; 378: 1277-1290
        • Rini BI
        • Plimack ER
        • Stus V
        • et al.
        Pembrolizumab plusaxitinib versus sunitinib for advanced renal-cell carcinoma.
        N Engl J Med. 2019;; 380: 1116-1127
        • Motzer RJ
        • Penkov K
        • Haanen J
        • et al.
        Avelumab plus axitinib versus sunitinib for advanced renal-cell carcinoma.
        N Engl J Med. 2019;; 380: 1103-1115
        • Choueiri TK
        • Powles T
        • Burotto M
        • et al.
        Nivolumab plus cabozantinib versus sunitinib for advanced renal-cell carcinoma.
        N Engl J Med. 2021;; 384: 829-841
        • Motzer R
        • Alekseev B
        • Rha SY
        • et al.
        Lenvatinib plus pembrolizumab or everolimus for advanced renal cell carcinoma.
        N Engl J Med. 2021;; 384: 1289-1300
        • Labbate C
        • Hatogai K
        • Werntz R
        • et al.
        Complete response of renal cell carcinoma vena cava tumor thrombus to neoadjuvant immunotherapy.
        J Immunother Cancer. 2019;; 7: 66
      1. Study of cabozantinib in combination with nivolumab and ipilimumab in patients with previously untreated advanced or metastatic renal cell carcinoma (COSMIC-313). Available at: https://clinicaltrials.gov/ct2/show/NCT03937219. Accessed March 22, 2022.

      2. Immunotherapy with nivolumab and ipilimumab followed by nivolumab or nivolumab with cabozantinib for patients with advanced kidney cancer, the PDIGREE study. Available at: https://clinicaltrials.gov/ct2/show/NCT03793166. Accessed March 22, 2022.