Better Biomarkers Needed for mRCC Treatment Planning

Recent years have brought the approval of 3 immunotherapy regimens for patients with metastatic renal cell carcinoma (mRCC). However, there is still a lack of clear biomarkers in this space. A better understanding could further improve treatment for this patient population.

The approvals include the combination use of ipilumumab (Yervoy) plus nivolumab (Opdivo) for intermediate- and poor-risk mRCC; the combination of axitinib (Inlyta) plus pembrolizumab (Keytruda) for advanced RCC; and the combination of axitinib plus avelumab (Bavencio) for advanced RCC

“The question is still, ‘How do we choose between these regimens?’” Ulka Vaishampayan, MD, a professor of oncology at Wayne State University, and chief of the Solid Tumor Program at Barbara Ann Karmanos Cancer Institute, said in an interview with OncLive, a sister publication of Oncology Nursing News.

"Right now, we have no validated biomarkers to guide our selection. Knowing whether a patient is likely to respond to an immune-based regimen or an anti-VEGF—based regimen could save a lot of toxicity and time for patients. Not everybody responds to immunotherapy, so a patient may be receiving 1 treatment while they could have benefited from another,” she said.

Vaishampayan explained that biomarkers from the International Metastatic Renal Cell Carcinoma Database Consortium Risk Score are currently being used to help determine which treatment patients should receive. They include: performance status, disease course, nephrectomy status, hemoglobin, calcium, lactate dehydrogenase, and white blood cell count.

But Vaishampayan hopes that there will 1 day be even better and more precise biomarkers.

“Going forward, the hope is that there will be a panel of biomarkers—like the angiogenesis panel that has been reported—that will allow us to select patients for a specific therapy based on risk stratification,” she said.

For now, toxicity is another major factor to consider when determining treatment for patients with mRCC. For example, the avelumab regimen has a lower instance of significant colitis, while the pembrolizumab combination can have an increased risk of transaminitis, according to Vaishampayan.

“Of course, patient convenience and how often patients are willing to come into the clinic is also considered when choosing between the 2 regimens,” she said.

Vaishampayan said that the biomarker question is, “the most interesting that is ongoing,” but there are still other unanswered questions in this field, too.

“We have published research looking at the neutrophil lymphocyte ratio. That has been shown to be potentially a predictive marker for immune therapy response. Of course, it needs to be validated in a much larger patient sample size before we can use it in the prime-time setting.”

A version of this article originally appeared on OncLive as, “Predictive Biomarkers Needed for Immunotherapy Combo Choice in Frontline RCC.”