![]() ![]() The clinical experts expected a durable sustained response after treatment that was not expected with treatment from a single TKI. This mode of action differed from a single TKI. The clinical experts explained that immunotherapy was expected to not only attack and kill the cancer cells, but also re-programme the immune system to recognise and adapt to attack and kill future cancer cells. This was because of the differences in the biological mode of action between an immunotherapy and a TKI. They suggested that a different survival trajectory between pembrolizumab with axitinib and sunitinib could be expected. But, this effect would be similar to that of other immunotherapy combinations for first-line renal cell cancer.ģ.5 Clinical experts expected that pembrolizumab with axitinib would offer a durable response, but they were not certain about the size of the response. The committee concluded that pembrolizumab with axitinib was likely to have a substantial effect on the care pathway. It is likely that subsequent treatment options would then be considered from a combination of current first-line and second-line options. The CDF clinical lead and the clinical experts explained that if patients have first-line treatment with pembrolizumab (a checkpoint inhibitor) plus axitinib (a tyrosine kinase inhibitor ), then they would be unable to have nivolumab (another checkpoint inhibitor) or axitinib monotherapy later in the treatment pathway. During technical engagement, clinical experts estimated that over 50% of people who had first-line treatment would have subsequent treatment. This is because of enhanced tolerability and a longer duration of disease control when using 2 effective treatments together (noting that the IMDC criteria corresponds to prognosis, rather than a score of frailty). Clinical experts expected that patients who are less frail would be offered combination therapy instead of single agents. Treatment options, in particular cabozantinib, can be difficult to tolerate because of the side effects. Nivolumab with ipilimumab is also only recommended for patients with intermediate or poor risk renal cell carcinoma, through the CDF. Cabozantinib is only recommended for patients with intermediate or poor risk renal cell carcinoma. ![]() Avelumab with axitinib is recommended through the Cancer Drugs Fund (CDF). Pazopanib is most likely to be used out of these. ![]() First-line options for treating metastatic renal cell carcinoma include tivozanib, sunitinib and pazopanib. 3.2 The committee considered the current treatment pathway for renal cell carcinoma. ![]()
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