After two years of complete response to Keytruda (pembrolizumab) and Inlyta (axitinib) treatment for kidney cancer, the decision to continue or stop therapy is complex and lacks definitive guidelines, according to Dr. Thomas Hutson, chief of the Hematology-Oncology Division at Texas Tech University Health Sciences Center School of Medicine.
The arbitrary two-year stop incorporated into Keytruda clinical trials was not based on specific scientific findings. While data suggest continuing Keytruda up to two years is beneficial, there is limited data on extending it beyond this period. In clinical practice, patients responding well to Keytruda without significant side effects typically complete the two-year course, followed by maintenance on Inlyta alone. Some physicians are now considering stopping Inlyta in patients with stable disease, although recurrence monitoring is essential.
The decision to discontinue Inlyta should involve a thorough discussion between the patient, their family, and their physician, weighing the side effects of the therapy against the risk of recurrence. Some patients may prefer to continue treatment indefinitely to minimize any risk of cancer recurrence, while others may opt to discontinue treatment and resume it if the cancer starts to progress again. Individual patient preferences and risk tolerance should guide this decision-making process.
Treatment Options for Non-Clear Cell Chromophobe Renal Cell Carcinoma
For patients with non-clear cell chromophobe renal cell carcinoma, several treatment options are available. Current guidelines from the National Comprehensive Cancer Network (NCCN) recommend using a combination of immunotherapy (IO) and tyrosine kinase inhibitors (TKI). Options include Lenvima (lenvatinib) plus Keytruda, or Cabometyx (cabozantinib) plus Opdivo (nivolumab).
Phase 2 trials have demonstrated the benefits of Lenvima and Keytruda, as well as CaboNivo, in chromophobe populations. The combination of Lenvima and Afinitor (everolimus) has also shown promise, particularly in chromophobe cancer, with the highest response rates observed in this subgroup. However, the FDA approval for Lenvima and Afinitor is limited to second-line therapy, restricting its use as a first-line option. Therefore, CaboNivo can be used as a first-line treatment, followed by Lenvima/Afinitor as a second-line option. Checkpoint inhibitors have also demonstrated some level of benefit in non-clear cell RCC.
Managing Fatigue and Chronic Kidney Disease
Severe fatigue in kidney cancer patients requires a comprehensive evaluation to identify potential secondary causes such as anemia, low steroid levels (adrenal insufficiency), low thyroid levels, or hormonal imbalances. If no reversible cause is identified, management strategies include sleep hygiene, exercise, and a review of medications that may contribute to fatigue. In some cases, physicians may consider stimulants to alleviate profound fatigue, but only after ruling out other underlying causes. Consultation with endocrinologists or palliative care specialists may also be beneficial.
Most kidney cancer patients have some degree of underlying renal impairment due to nephrectomy or kidney mass. While the majority of patients can manage this impairment without significant issues, severe cases may require nephrologist involvement. Although kidney cancer therapies can impact kidney function, most patients do not need hemodialysis. For patients with significant renal impairment, protein intake may need to be adjusted under the guidance of a nephrologist, who may recommend either increasing or decreasing protein intake based on individual needs.
