Background Dual immunotherapy (ipilimumab/nivolumab, IO/IO) and immunotherapy/tyrosine kinase inhibitor (IO/TKI) combinations (e.g. pembrolizumab/axitinib) are approved for first-line therapy of intermediate/poor risk metastatic renal cell carcinoma (RCC),1–4 but there is limited comparative data between these two options. We sought to understand how physicians decide between IO/IO vs. IO/TKI for this indication.
Methods We sent a 10-question survey focused on a patient scenario of intermediate/poor risk metastatic RCC to 294 general and academic/disease-focused oncologists throughout the country using RedCAP software to solicit treatment preferences and rationale.
Results We received 105 responses (36% response rate): 61% (64) of providers chose IO/IO, 39% (41) chose IO/TKI (figure 1). 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 = 0.004 (figure 2). 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) (figure 3). 88% (92) of all 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.
Conclusions In response to a representative patient scenario of intermediate-risk 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 being more likely to choose IO/IO. The vast majority of oncologists would be comfortable enrolling patients into a phase III trial comparing IO/IO vs. IO/TKI, demonstrating equipoise in the community regarding this question and providing support for such a trial.
Motzer RJ, Tannir NM, McDermott DF. Nivolumab plus Ipilimumab versus Sunitinib in Advanced Renal-Cell Carcinoma. N Engl J Med 2018;378(14):1277–1290.
Rini BI, Plimack ER, Stus V. Pembrolizumab plus Axitinib versus Sunitinib for advanced Renal-Cell Carcinoma. N Engl J Med 2019;380(12):1116–1127.
Choueiri TK, Powles T, Burotto M. Nivolumab plus Cabozantinib versus Sunitinib for advanced Renal-Cell Carcinoma. N Engl J Med 2021;384(9):829–841.
Motzer R, Alekseev B, Rha SY. Lenvatinib plus Pembrolizumab or Everolimus for advanced renal cell Carcinoma. N Engl J Med 2021;384(14):1289–1300.
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