evidencia disponible en subgrupos de pacientes javier puente, md, phd hospital universitario clinico...
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Evidencia disponible en subgrupos de pacientes
Javier Puente, MD, PhDHospital Universitario Clinico San Carlos
Medical Oncology DepartmentComplutense University
Associate Professor of Medicine
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Targeted agents currently approved for mRCC in Europe
Sorafenib (oral)Advanced RCC after IFN‑α/IL-2 or if
unsuitable for IFN-α/IL-22
Bevacizumab (+IFN-α) (IV)
First-line mRCC3
Everolimus (oral)Advanced RCC after
VEGF targeted therapy‑ 5
Axitinib (oral)Advanced RCC after sunitinib or a
cytokine7
Temsirolimus (IV)Advanced RCC with 3–6 prognostic
risk factors4
2006 2007 2008 2009 2010 2011 2012 2013 2014
Pazopanib (oral)Advanced RCC6
Sunitinib (oral)Advanced/mRCC1
1. Sunitinib SmPC, Jan 2014; 2. Sorafenib SmPC, Feb 2013; 3. Bevacizumab SmPC, Feb 2014; 4. Temsirolimus SmPC, Oct 2013; 5. Everolimus SmPC, Nov 2013; 6. Pazopanib SmPC, Dec 2013; 7. Axitinib SmPC, Oct 2013.
IFN-α, interferon-alpha; IL-2, interleukin-2; IV, intravenous
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Evolution in the first-line treatment of mRCC
Med
ian
su
rviv
al (
mo
nth
s)
PFS OS
3–6
6–15*
13–22
18–32*
After AfterBefore Before
30
25
20
15
10
5
0
Median survival before and after the introduction of targeted agents (TKIs)1–11
1. Coppin et al. Cochrane Database Syst Rev 2005; 2. Gore et al. Lancet 2010; 3. Motzer et al. N Engl J Med 2007; 4. Escudier et al. Lancet 2007; 5. Rini et al. J Clin Oncol 2008; 6. Motzer et al. N Engl J Med 2013; 7. Motzer et al. J Clin Oncol 2009; 8. Escudier et al. J Clin Oncol 2010; 9. Rini et al. J Clin Oncol 2010; 10. Michel et al. ASCO GU 2014; 11. Motzer et al. ASCO 2013.
*With targeted agents as first-line mRCC therapy primarily in favourable/intermediate risk patients
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Have we improved OS since 2006?
2007/20131,2 2010/20132,320134
20145 20145 20136
1. Motzer et al. J Clin Oncol 2009; 2. Motzer et al. N Engl J Med 2013; 3. Sternberg et al. Eur J Cancer 2013; 4. Motzer et al. J Clin Oncol 2013; 5. Michel et al. ASCO GU 2014; 6. Motzer et al. ASCO 2013.
Med
ian
OS
, m
on
ths
Please refer to local prescribing information for each treatment option
Median OS for VEGF-targeted therapies in mRCC in clinical studies
Eve. Everolimus; Seq., sequence; Sor, sorafenib; Sun, sunitinib
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First-line
Second-line
1. Escudier et al. Ann Oncol 2012; 2. Corrigendum Ann Oncol 2013; 3. Temsirolimus SmPC, Oct 2013.
Second-line targeted treatment options: VEGFR-TKI or mTOR inhibitor?
mRCC1,2
Temsirolimus*
Poor prognosisGood/intermediate prognosis
VEGFR-TKI or mAb-VEGF-A+IFNα
mTOR inhibitorVEGFR-TKI
*Temsirolimus is indicated for the first-line treatment of advanced RCC with 3-6 prognostic risk factors3; mAb, monoclonal antibody
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Introduction
With the arrival of targeted therapies, the treatment paradigm for mRCC has become increasingly complex
Maximising the long-term benefit of these agents requires informed decision-making based on both…
Clinical trial data Real-world experience
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In this symposium we will explore…
• assess the current treatment paradigm for mRCC
• assess the importance of maximising treatment lines
Clinical evidence, to…
Evidence from the real world, clinical practice, and real-life case studies, to…
• assess how best to optimise the treatment options available
• help make informed treatment decisions for each individual patient
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Special subgroups of patients
- ELDERLY PATIENTS
- PERFORMANCE STATUS 2
- BRAIN METASTASES
- COMORBILITIES (CARDIAC DISORDES, RENAL FAILURE, …)
- NON CLEAR CELL CARCINOMA
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Percent of New Cases by Age Group: Kidney and Renal Pelvis Cancer
Median age at diagnostic:
64
SEER 18 2007-2011, All Races, Both Sexes
48,3% ≥ 65
23,1% ≥ 75
Percent of new cases by age group
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Median age in pivotal studies
Drug Nº patients Benefit (months)
Median age %>70 years
Sunitinib 750 6 62 [27-87] NR
Sorafenib 903 2,7 59 [19-86] 16%
Beva-IFN 649 y 732
4,8 y 3,3
61 [30-82]61 [56-70]
NR
Temsirolimus 626 2,4 58 [32-81] NR
Everolimus 410 2,1 61 [27-85] NR
Pazopanib 435 5 59 [25-85] 35% (>65 a)
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Efficacy is mantained regardless of age
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Efficacy and safety of sunitinib in elderly patients with mRCC
Hutson TE, et al. Efficacy and safety of sunitinib in elderly patients with metastatic renal cell carcinoma. Br J Cancer. 2014 Mar 4;110(5):1125-32.
N= 1059 (19% ≥70 a)
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Efficacy and safety of sunitinib in elderly patients with mRCC
Hutson TE, et al. Efficacy and safety of sunitinib in elderly patients with metastatic renal cell carcinoma. Br J Cancer. 2014 Mar 4;110(5):1125-32.
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Hutson TE, et al. Efficacy and safety of sunitinib in elderly patients with metastatic renal cell carcinoma. Br J Cancer. 2014 Mar 4;110(5):1125-32.
More common (P<0.05) in patients aged ≥70 years:• Fatigue• Cough• Anemia• Peripheral edema• Thrombocytopenia• Decreased weight• Decreased appetite• Dizziness• Hypothyroidism• Dehydration• Urinary tract infection
Efficacy and safety of sunitinib in elderly patients with mRCC
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Expanded Access Program: experience in elderly patients
Drug Nº patients
%≥70 years Median age Efficacy
Sunitinib (Gore) 4564 1418 (32%)(Nota:≥65 a)
59 [19-89] SLP global: 10,9 mSG global: 18,4 m
SLP ≥65 a: 11,3 m SG ≥65 a: 18,2 m
Sorafenib Europeo (Beck)
1159 267 (23%) 62 [18-84] SLP global: 6,6 mTP: 7,9 mSLP ≥70 vs <70 a: 8,0 vs 6,4 m (ns)
SorafenibNorteamericano (Stadler)
2504 736 (29%) 63 [13-93] SLP global: 36 semSG global: 50 semSLP ≥70 vs <70 a: 46 sem vs 50 (ns)
Everolimus (Grünwald)
1367 592 (43.3%)(Nota:≥65 a)
63 [23-87] Median treatment global: 14 sem
Gore et al. Lancet Oncol 2009; Beck et al Ann Oncol 2011; Stadler, et al. Cancer 2010; Bukowski, et al. Oncology 2010
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Dosing decisionsTreatment duration
decisionsToxicity management
decisions
Personalising treatment to maximise outcomes with targeted therapy: experience from the real world
How can we select the best treatment for these patients?
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Standard vs adapted sunitinib regimen in elderly patients with mRCC
De Giorgi et al. Clin Genitorinary Cancer 2013; 12(3): 182-9
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11 meses 25.5 meses
De Giorgi et al. Clin Genitorinary Cancer 2013; 12(3): 182-9
Standard vs adapted sunitinib regimen in elderly patients with mRCC
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Why dose titrate?
Dose titration allows treatment to be
personalised with maintenance of
therapeutic drug levels, which are associated with
better outcomes
Efficacy is the main driver in RCC
treatment
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RAINBOW study: modified sunitinib scheduling in patients with mRCC
Retrospective observational study of mRCC patients administered sunitinib on a 2/1 schedule*
Group A (n=208)Sunitinib
50 mg/day*Switched from schedule 4/2 to 2/1 due to TEAE
Group B (n=41)Sunitinib
50 mg/day*Schedule 2/1 ab initio due to
poor clinical condition
Objective Evaluate efficacy
and safety of 2/1 vs 4/2 schedule
Eligibility criteria Patients with
advanced RCC
N=276
BASELINE
Group C (n=27)Sunitinib
50 mg/day*Schedule 4/2 (control)
Safety endpoint: Incidence of adverse eventsEfficacy endpoint: PFS and treatment duration *Dose reductions were possible
TEAE, treatment-emergent adverse events
Bracarda et al. ASCO GU 2014
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RAINBOW study: AE rate in patients switched from 4/2 to 2/1 schedule
Rat
e (%
)
† ‡ § ¶
*p<0.001; †p=0.008; ‡p=0.063; §p=0.003; ¶p=0.007HFS, hand-foot syndrome
Bracarda et al. ASCO GU 2014
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Toxicity evaluation after 2 weeks on first course
Modify dose/schedule
DL-1: Pts than cannot take 50 mg for 28 d- 50 mg individualized # of days / 7 days off
DL-2: Pts than cannot take 50 mg for at least 7 d- 37.5 mg individualized # of days / 7 days off
DL-3: Pts than cannot take 37.5 mg for at least 7- 25 mg individualized # of days / 7 days off
≤ Grade-1 toxicity:Continue Rx
≥ Grade-2 toxicitybefore 4 weeks:Stop Rx for 7 d**
≤ Grade-1 toxicityAt 4 weeks:
Stop Rx for 7 d**
Grade-2 toxicityAt 4 weeks:
Stop Rx for 7 d**
Reduce off-Rx time to 7d**
DL+: 50mg 28/7d
Escalate dose/modify
schedule
DL+1: 62.5 mg 14/7
DL+2: 75.0 mg 14/7
Toxicity evaluation after 4 weeks on first course
≥ Grade-2 toxicity:Stop Rx for 7 d**
Sunitinib Titration Study (Bjarnason et al. ESMO 2014)
** Or until toxicity has resolved
Individually maximize days on Rx during continued therapy based on toxicity
Sub
sequ
ent
Cyc
les
Firs
t cy
cle
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Current dose schedule distribution for 91 pts:
Sunitinib dose (mg)
Schedule(d on/off)
# patients currently or when came off study
59.3% of patient with improved dose intensity vs. standard dose criteria
75 14/7 4
18 pts (19.8%)dose escalated
75 10/7 1
62.5 16/7 1
62.5 14/7 11
62.5 7/7 1
50 28/7 19 Many recently entered on study
50 28/14 3
50 24/7 136 pts (39.5%)
50 mg dose maintainedbut for fewer days on
Would have been dose reduced by standard criteria
50 20/7 1
50 16/7 4
50 14/7 18
50 9/7 2
50 7/7 10
37.5 28/7 and 90/7 211 pts (12%) reduced to 37.5 mg
(36 - 63% in rand trials)1-437.5 14/7 5
37.5 5-7/7 4
25 28-42/7 14 pts (4.4%) reduced to 25 mg
(27- 43% in rand trials) 1-425 14/7 1
25 7/7 2
4 pts (4.4%) d/c early due to toxicity (15 - 19% in rand trials) 1-4
1. Motzer RJ, Hutson TE, Olsen MR et al. J Clin Oncol 2012; 30: 1371-1377. 2. Motzer RJ, Hutson TE, Tomczak P et al. J Clin Oncol 2009; 27: 3584-3590.3. Barrios C, Hernandez-Barajas D, Brown M et al. ESMO conference 2009; Abstract 7122.4. Escudier B, Roigas J, Gillessen S et al. J Clin Oncol2009; 27: 4068-4075.
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Response data for 65 evaluable pts
Individ Sunitinib
dosing
EFFECT50 mg dose
Sunit data vs. INF
Phase-III
Pazo datavs. Sut
Phase-III
Axitinib data vs. Sorafenib
Phase-III
N 65 146 335 557 192
CR % 4.6 (n=3) 0 0 <1 0
PR % 50.8 (n=33) 32 31 31 32
CR+PR % 55.4* (n=36) 32 31 31 32
SD % 33.8 (n=22) 43 48 39 43
CR+PR+SD 89.2 (n=58) 75 79 70 72
PD % 10.8 (n=7) 25 21 17 10
PFS (mo) n/a 8.5 11 8.4 10.1*Similar to RR for Axitinib dose titration arm (n=56)
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Motzer RJ, et al. Interferon-Alfa as a Comparative Treatment for Clinical Trials of New Therapies Against Advanced Renal Cell Carcinoma. J Clin Oncol. 2002 Jan 1;20(1):289-96.
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Heng DY, Xie W, Regan MM, et al. Prognostic factors for overall survival in patients with metastatic renal cell carcinoma treated with vascular endothelial growth factor-targeted agents: results from a large, multicenter study. J Clin Oncol. 2009; 27: 5794-5799.
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Outcome of patients with mRCC that do not meet eligibility criteria for clinical trials
8,6 vs 5,0 meses28.4 vs 12.5 meses
Heng DY, et al. Annals of Oncology 25: 149–154, 2014.
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Gore M, et al. ESMO 2011
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Annals of Oncology 23: 973–980, 2012
Retrospectivo: 11157 pacientes
Brain Metastases: Epidemiology
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903 TARGET 139
Annals of Oncology 21: 1027–1031, 2010
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Cancer. 2011 Feb 1;117(3):501-9
Safety and efficacy of sunitinib for mRCC with brain metastases
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Non-clear Cell Renal Cell CarcinomaDescription and Prevalence
• nccRCC represents a diverse group of tumors with varying genetic and histologic characteristics1,2
– Approximately 25% of RCC cases are nccRCC1
• Many nccRCC subtypes have only recently been described as discrete entities; some are considered new and emerging, and others remain unclassified2
32
1. Cohen HT et al. N Engl J Med. 2005;353:2477-2490.2. Srigley JR et al. Mod Pathol. 2009; 22 (suppl 2): S2-S23.
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Temsirolimus ARCC Trial: OS and PFS1,2
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ARCC, advanced renal cell carcinoma.
1. Hudes G et al. N Engl J Med. 2007;356:2271-2281.2. Dutcher JP et al. Med Oncol. 2009;26:202-209.
Overall Survival
INF-α Temsirolimus Temsirolimus vs INF-α
Median (mo, 95% CI) Median (mo, 95% CI) HR (95% CI)
ccRCC 8.2 (6.6 – 10.4) 10.7 (8.5 – 13.0) 0.82 (0.64 – 1.06)
nccRCC 4.3 (3.2 – 7.3) 11.6 (8.9 – 14.5) 0.49 (0.29 – 0.85)
Progression-free Survival
INF-α Temsirolimus Temsirolimus vs INF-α
Median (mo, 95% CI) Median (mo, 95% CI) HR (95% CI)
ccRCC 3.7 (2.5 – 4.6) 5.5 (3.8, 7.1) 0.76 (0.60 – 0.97)
nccRCC 1.8 (1.6 – 2.1) 7.0 (3.9 – 8.9) 0.38 (0.23 – 0.62)
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Tumor response (per RECIST), n (%)
Number of evaluable patients All (n = 3464) Non-clear cell histology (n = 437)
OR 603 (17) 48 (11)
CR 34 (1) 2 (<1)
PR 569 (16) 46 (11)
SD ≥ 3 months 2029 (59) 250 (57)
PR or SD < 3 months 832 (24) 139 (32)
Clinical benefit* 2632 (76) 298 (68)
Summary of Median PFS and OS
Number of evaluable patients All (n = 4349) Non-clear cell histology (n = 588)
PFS, months (median; 95% CI) 10.9 (10.3 – 11.2) 7.8 (6.3 – 8.3)
OS, months (median; 95% CI) 18.4 (17.4 – 19.2) 13.4 (10.7 – 14.9)
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OR, objective response. *Clinical benefit = OR + SD for ≥ 3 months.
Gore ME et al. Lancet Oncol. 2009;10:757-763.
Safety and efficacy of sunitinib for non clear cell carcinoma (EAP)
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SUPAP: Phase 2 Trial of First-Line Sunitinib in Papillary mRCC
35
Primary end point: • objective tumor responseSecondary end points: • safety, OS, PFS, time to response,
duration of response
Eligibility Criteria• Age ≥18 years • Locally advanced or metastatic,
histologically confirmed type1 or 2 papillary RCC
• Measurable disease by RECIST• ECOG PS ≤1• No prior systemic therapy for
mRCC (including sunitinib)
Sunitinib 50 mg/d;4 weeks on/2 weeks off
N = 61
Type 1: n = 15Non-type 1: n = 46
Disease progression or unacceptable
toxicity
Open-label, single-arm phase 2 study
• 61 patients were enrolled (15 with type 1; 46 with non-type 1)
• Two-stage study design based on SIMON 2-step method: 21 patients are included to achieve a 20% ORR. If ≥2 patients achieve this goal, 20 additional patients are added
• A separate, identical study in patients with type 1 or non-type 1 tumors was conducted
Ravaud A et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress;September 28–October 2, 2012; Vienna, Austria.
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SUPAP Interim Analysis:Patient Characteristics (1)
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All, n (%)N = 61
Type 1, n (%)n = 15
Non-type 1, n (%)n = 46
Age, y (Median, min-max) 64 (32–81) 69 (53–8-0) 61 (32–81)
Female (%) 10 (16) 1 (7) 9 (20)
Nephrectomy
Yes 53 (87) 115 (100) 38 (83)
No 8 (13) — 8 (17)
Metastatic site
>1 site 55 (90) 13 (87) 42 (91)
Lung 38 (62) 13 (87) 25 (54)
Retroperitoneal lymph nodes 33 (54) 7 (47) 26 (57)
Mediastinum 29 (48) 6 (40) 23 (50)
Bone 17 (28) 6 (40) 11 (24)
Liver 11 (18) — 11 (24)
Other 27 (44) 8 (53) 19 (41)
MSKCC Group
0 Favorable 12 (22) 4 (29) 8 (20)
1-2 Intermediate 33 (61) 7 (50) 26 (65)
≥3 Poor 9 (17) 3 (21) 6 (15)
Undetermined 7 (–) 1 (–) 6 (–)
Ravaud A et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress; September 28–October 2, 2012; Vienna, Austria.
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SUPAP Interim Analysis:Best Response
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Best Response , n (%) All, n (%)N = 61
Type 1, n (%)n = 15
Non-type 1, n (%)n = 46
Assessable patients 60a (100) 15b (100) 45c (100)
Partial response (PR) 7 (12) 2 (13) 5 (11)
Stable disease (SD) 35 (58) 10 (67) 25 (56)
SD ≥12 weeks 15 (25) 5 (33) 10 (22)
Progression 18 (30) 3 (20) 15 (33)
Objective response rate (95% CI) 12% (3%–20%) 13% (0%–31%) 11% (2%–20%)
Nonprogression rate (95% CI) 70% (58%–82%) 80% (60%–100%) 67% (53%–80%)
aOne patient died before first tumor evaluation from a cause other than disease progression.bOne patient has been reviewed as type 2 (with a PR).cTwo patients have been reviewed as type 1 (both with SD), 1 as a nonpapillary type (with a PR) and 1 as doubtful (with a SD).
Ravaud A et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress;September 28–October 2, 2012; Vienna, Austria.
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SUPAP Interim Analysis:
PFS
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*Product limit survival estimate with number of patients at risk.PFS, progression-free survival.
Ravaud A et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress;September 28–October 2, 2012; Vienna, Austria.
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SUPAP Interim Analysis: OS
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Su
rviv
al
Pro
ba
bil
ity
*Product limit survival estimate with number of patients at risk.
Ravaud A et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress;September 28–October 2, 2012; Vienna, Austria.
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Nonrandomized,
single-group assignment
Phase 2 Trial of Everolimus in Patients With mRCC and Non-Clear Cell Histology
Study Design1-3
A total of 49 patients were enrolled from 5 centers; 23 patients had been treated with VEGF-TKI prior to the study enrollment
Median age was 57 years (range 24 ‒ 75 years) and male to female ratio was 37:12 Histology of the patients included papillary (n = 29), chromophobe (n = 8), collecting duct (n = 2),
sarcomatoid (n = 4), and unclassifiable carcinoma (n = 6)
40
Everolimus 10 mg/day orally
Disease progression or unacceptable toxicity
Study start Study end
Primary end point:• PFS
Secondary end points:• Objective response rate• Clinical benefit rate• Disease control rate• Safety
Key eligibility criteria:
≥ 18 years old with mRCC of non clear-cell histology, with or without previous VEGF-TKI therapy
ECOG PS 0 or 1
Key exclusion criteria:
Previous use of an mTOR inhibitor
Clinically uncontrolled CNS metastasis
Interstitial pulmonary disease
ECOG PS, Eastern Cooperative Oncology Group Performance Status.
1. Koh Y et al. J Clin Oncol. 2012;30(suppl):abstract 4544.2. Koh Y et al. Poster presented at the ASCO annual meeting, June 1-5, 2012, Chicago, Illinois.3. ClinicalTrials.gov Identifier: NCT00830895.
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Phase 2 Trial of Everolimus in Patients With mRCC and Non-Clear Cell Histology: Efficacy and Safety1,2
Toxicity profiles were commensurate with previous reports of everolimus in patients with mRCC
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Outcomes Everolimus (10 mg/d) N = 49
Best overall response, (n) %
Partial response 5† (10.2)
Stable disease 25 (51.0)
Progressive disease 16 (32.7)
Not eligible for assessment 3 (6.1)
Median PFS, months 5.2
ORR, % 10.2
CBR, % 57.1
DCR, % 61.2
ORR, objective response rate; CBR, clinical benefit rate; DCR, disease control rate.
1. Koh Y et al. J Clin Oncol. 2012;30(suppl.): abstract 4544.2. Koh Y et al. Poster presented at the ASCO annual meeting, June 1-5, 2012, Chicago, Illinois.
Efficacy of EverolimusAccording to Histology
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RAPTOR Phase 2 Trial of First-Line Everolimus in Papillary mRCC1,2
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Primary end point: • Proportion of patients progression free at 6 monthsSecondary end points: • DCR, ORR, duration of response, median PFS, safety
Eligibility Criteria• Age ≥18 years • Metastatic papillary RCC• Measurable disease• ECOG PS ≤1• No prior mTOR inhibitor• No prior systemic therapy
for mRCC (including VEGF or mTOR inhibitors
International, multicenter,open-label study
1. ClinicalTrials.gov identifier: NCT00688753.2. Escudier B et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress;
September 28–October 2, 2012; Vienna, Austria.
Trial Sites: Belgium, France, Germany, Italy, Poland, Spain
Everolimus 10 mg/dN = 92
Disease progression or unacceptable
toxicity
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RAPTOR Interim Analysis:Patient Characteristics
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Escudier B et al. Presented at the 37th European Society for Medical Oncology (ESMO) Congress;September 28–October 2, 2012; Vienna, Austria.
Sex, n (%)
Female 20 (21.7)
Male 72 (78.3)
Age, y
n 92
Mean (SD) 59.9 (14.9)
Median 62.0
Range 23–84
Patients with PS, n (%)
0 56 (60.9)
1 36 (39.1)
MSKCC, n (%)
Favorable 48 (52.2)
Intermediate 38 (41.3)
Poor 1 (1.1)
Missing 5 (5.4)
Nephrectomized patients, n (%)
No 16 (17.4)
Yes 76 (82.6)
Organs with lesions, n (%)
1 organ 13 (14.1%)
2 organs 23 (25.0%)
>2 lesions 48 (52.2%)
Missing 8 (8.7%)
Time from diagnosis to treatment
n 88
Mean (SD) 788.56 (1218.70)
Median 209.50
Range 14.0–5451.0
Type
Type 1 23 (25.0)
Type 2 39 (42.4)
Missing 30 (32.6)
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RAPTOR Final Analysis: PFS, OS (ASCO GU 2014)
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*Kaplan-Meier estimate for the proportion of patients without PFS event (progression or death due to any cause)..
Escudier B et al. Presented at the ASCO GU 2014
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ESPN TRIAL Everolimus versus Sunitinib prospective evaluation in metastatic non-clear cell carcinoma1
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1. Tannir E, ASCO 2014 (Abstract 4505)
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ESPN TRIAL: PFS in First Line (Primary Endpoint)
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1. Tannir E, ASCO 2014 (Abstract 4505)
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ESPN TRIAL: Overall Survival47
1. Tannir E, ASCO 2014 (Abstract 4505)
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Conclusions: What have we learnt?
What the current treatment paradigm is in mRCC The importance of maximising therapy lines in mRCC That efficacy is the main driver in RCC treatment
Real-world data
Real-life case studies
Strategies to personalise targeted therapy to maximise outcomes
Dosing, treatment duration and toxicity management decisions
Clinical evidence
The value of maximising mRCC therapy in daily clinical practice
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THANK YOU
Javier Puente, MD, PhDHospital Universitario Clinico San Carlos
Medical Oncology DepartmentComplutense University
Associate Professor of Medicine