FRACTION-RCC: nivolumab plus ipilimumab for advanced renal cell carcinoma after progression on immuno-oncology therapy

Abstract

Background

The role and sequencing of combination immuno-oncology (IO) therapy following progression on or after first-line IO therapy has not been well-established. The Fast Real-time Assessment of Combination Therapies in Immuno-ONcology (FRACTION) program is an open-label, phase 2 platform trial designed to evaluate multiple IO combinations in patients with advanced renal cell carcinoma (aRCC) who progressed during or after prior IO therapy. Here, we describe the results for patients treated with nivolumab plus ipilimumab. For enrollment in track 2 (reported here), patients with histologically confirmed clear cell aRCC, Karnofsky performance status ≥70%, and life expectancy ≥3 months who had previously progressed after IO (anti-programmed death 1 (PD-1), anti-programmed death-ligand 1 (PD-L1), or anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4)) therapy were eligible. Previous treatment with anti-CTLA-4 therapy plus anti-PD-1/PD-L1 therapy precluded eligibility for enrollment in the nivolumab plus ipilimumab arm. Patients were treated with nivolumab 3 mg/kg plus ipilimumab 1 mg/kg every 3 weeks for four doses, followed by nivolumab 480 mg every 4 weeks for up to 2 years or until progression, toxicity, or protocol-specified discontinuation. The primary outcome measures were objective response rate (ORR), duration of response (DOR), and progression-free survival (PFS) rate at 24 weeks. Secondary outcomes were safety and tolerability up to 2 years. Overall survival (OS) was a tertiary/exploratory endpoint. Overall, 46 patients were included with a median follow-up of 33.8 months. The ORR was 17.4% (95% CI, 7.8 to 31.4) with eight (17.4%) patients achieving partial response. Stable disease was achieved in 19 (41.3%) patients, while 14 (30.4%) had progressive disease. Median DOR (range) was 16.4 (2.1+ to 27.0+) months. The PFS rate at 24 weeks was 43.2%, and median OS was 23.8 (95% CI, 13.2 to not reached) months. Grade 3–4 immune-mediated adverse events were reported in seven (15.2%) patients. No treatment-related deaths were reported. Patients with aRCC treated with nivolumab plus ipilimumab may derive durable clinical benefit after progression on previous IO therapies, including heavily pretreated patients, with a manageable safety profile that was consistent with previously published safety outcomes. These outcomes contribute to the knowledge of optimal sequencing of IO therapies for patients with aRCC with high unmet needs.

Trial registration number

NCT02996110.

Correspondence to Dr Toni K Choueiri; [email protected]

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Immuno-oncology (IO) options, including immune checkpoint inhibitor (ICI) monotherapy and combination therapies, currently constitute the backbone of both first-line and second-line treatments for patients with advanced renal cell carcinoma (aRCC).

• Despite the promising efficacy of IO combination treatments, disease progression is inevitable for many patients, and no standard of care exists for those whose ICI combination treatment failed.

• The optimal selection and sequencing of IO treatment after progression on IO therapy is not well known.

WHAT THIS STUDY ADDS

• The Fast Real-time Assessment of Combination Therapies in Immuno-ONcology Study in Patients With aRCC (FRACTION-RCC) is a signal-seeking randomized phase 2 trial with an adaptive-platform design that enables evaluation of IO combinations in patients with aRCC who had previously progressed on IO therapy.

• The observed outcomes in this IO pretreated patient population contribute to the knowledge on optimal sequencing of IO therapies for patients with aRCC.

• The findings show ongoing clinical benefits among some patients receiving nivolumab plus ipilimumab after progression on previous IO therapies, with a manageable safety profile that was consistent with previously published safety outcomes.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• There is a persistent unmet need for patients in the IO pretreated setting, and this study contributes to the limited evidence on which to base future treatment decision-making, and hopefully will stimulate the conduct of additional prospective studies in this patient population.

• Clinical benefits were realized among some patients receiving nivolumab plus ipilimumab after progression on previous IO therapies; therefore, this combination may be a viable option for select patients after progression on IO therapy

Background

Since the introduction of tyrosine kinase inhibitors (TKIs) and mammalian target of rapamycin (mTOR) inhibitors in the early 2000s, the management of advanced renal cell carcinoma (aRCC) has progressed into an era where combination immuno-oncology (IO) treatment has become the standard of care.^1–8 Immune checkpoint inhibitors (ICIs) in particular have revolutionized the treatment paradigm for aRCC, reflecting a fundamental shift in the approach to treating aRCC by leveraging the immune system to attack cancer cells, rather than targeting pathways underlying tumor pathogenesis, as with TKIs or mTOR inhibitors.^{1 2 9 10}

Nivolumab was the first-in-class ICI, targeting the programmed death 1 (PD-1) checkpoint in aRCC.¹¹ US Food and Drug Administration (FDA) approval was granted on the basis of results from the CheckMate 025 phase 3 clinical trial in 2015, which compared nivolumab and everolimus in the second-line and third-line settings, in which nivolumab demonstrated superiority.^{1 11 12}

After the successes of IO therapy in patients with disease progression on conventional targeted therapies, the randomized phase 3 pivotal CheckMate 214 trial evaluated combination immune checkpoint blockade in treatment-naïve patients with advanced clear cell RCC, resulting in FDA approval of nivolumab plus ipilimumab in patients with International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) intermediate or poor risk.^{9 13 14} Thereafter, approaches incorporating dual immune checkpoint blockade with a PD-1 or programmed death ligand 1 (PD-L1) inhibitor along with cytotoxic T-lymphocyte antigen 4 (CTLA-4) inhibition, or immune checkpoint blockade plus a vascular endothelial growth factor (VEGF)-targeted therapy, has become an accepted standard of care for treatment-naïve aRCC on the basis of unprecedented response rates and improved survival.^1–10 Nivolumab is now widely used in monotherapy or in combination for the treatment of aRCC, and the clinical benefit of IOs and their combination with antiangiogenic agents is evident in both untreated and treated patients with aRCC.^{3 11 15} IO options currently constitute the backbone of both first-line and second-line treatments.^{1 3 13}

Despite the promising efficacy of these combination treatments, disease progression is inevitable for many patients, and no standard of care exists for those who did not respond to an ICI combination in the first-line setting.^{1 9 15 16} In clinical practice, the potential benefits of ICIs or ICI combinations when given beyond the first-line and second-line setting have not been fully elucidated.^{9 13} When patients develop resistance or toxicity to immune checkpoint blockade in the first-line treatment of aRCC, a new challenge has emerged regarding how to optimally treat patients in the second-line and beyond in patients who have received prior IO therapy.^{1 2 13} Several studies investigated the addition of ipilimumab to nivolumab in a sequential manner and showed that this approach was not always feasible and of limited benefit, with efficacy appearing to be less than that of concomitant nivolumab plus ipilimumab in untreated patients with intermediate/poor-risk disease (CheckMate 214 trial).^{14 17–21} Data from OMNIVORE, TITAN-RCC, and HCRN GU16-260-cohort A did not support a response-adaptive strategy for PD-1/CTLA-4 inhibitors in metastatic RCC.^17–21

Ongoing efforts are focused on the sequencing of subsequent-line options after progression on IO monotherapy or combination therapies.^{1 2 9 16 22} A small number of recent retrospective analyses have suggested that patients whose disease progressed after IO therapy may derive substantial benefit from single-agent ICI and ICI combinations in later treatment lines as well.^{1 2 9 16 22}

Thus far, although the optimal sequencing of ICI treatment across different lines of treatment is neither supported by high-level prospective evidence nor by treatment guidelines, real-world evidence suggests that heavily pretreated patients may benefit from treatment with ICI or ICI combinations.^{1 2 9 16 22} This underscores the unmet need for patients in the IO therapy pretreated setting, and ongoing clinical trials will provide insights on which to base future best practice and guideline recommendations.

The Fast Real-time Assessment of Combination Therapies in Immuno-ONcology Study in Patients With aRCC (FRACTION-RCC) is a signal-seeking randomized phase 2 trial with an adaptive-platform design that enables evaluation of IO combinations.²³ FRACTION-RCC assesses efficacy and safety outcomes with nivolumab plus ipilimumab in patients with aRCC who are either IO-treatment naïve (track 1) or whose disease previously progressed during or after IO (track 2); we focus here on track 2. To our knowledge, FRACTION-RCC is the first and only adaptive platform study to prospectively evaluate IO combination regimens in patients with aRCC progressing after previous IO therapy.

Methods

The master FRACTION study design was described previously.²³ At present, the study is no longer recruiting and no patients remain on study. FRACTION-RCC aims to determine the most promising IO therapy combinations available for patients with aRCC, thus reducing the time and number of patients needed to identify potentially beneficial regimens for evaluation in phase 2 or 3 trials.²³ Patients were enrolled in one of the two tracks (online supplemental figure 1). Track 1 enrolled patients with aRCC who were naïve to IO treatment (anti-PD-1/anti-PD-L1, and anti-CTLA-4) and were stratified according to whether the patient had prior TKI treatment, and track 2 enrolled patients with previous IO treatment experience. Patients in both tracks were randomized to receive nivolumab plus ipilimumab or other treatment combinations, all of which included nivolumab (online supplemental figures 1 and 2). Patients whose disease progressed were eligible for enrollment in another track 2 FRACTION regimen that differed from what the patient previously received. This report focuses on outcomes in patients randomized to nivolumab and ipilimumab in track 2 and includes mature follow-up data.²³

Patients with histologically confirmed clear cell aRCC, life expectancy ≥3 months, and Karnofsky performance status ≥70% whose disease progressed on any previous line of anti-PD-1/anti-PD-L1 or anti-CTLA-4 treatment were assigned to receive nivolumab 3 mg/kg plus ipilimumab 1 mg/kg every 3 weeks for four doses, followed by nivolumab 480 mg monotherapy every 4 weeks for up to 2 years or until disease progression, toxicity, or protocol-specified discontinuation.²³ Patients who were previously treated with anti-CTLA-4 therapy in combination with anti-PD-1/PD-L1 therapy were not eligible for enrollment in the nivolumab plus ipilimumab arm of track 2 per the subprotocol. Patients who were intolerant to or progressed on nivolumab plus ipilimumab were eligible to be randomized to other FRACTION-RCC regimens within track 2. All patients provided an institutional review board-approved written consent before entering the screening phase.

Sample sizes were guided by Simon two-stage (optimal) designs. Recommendations for stopping or progressing to the next stage were based on the number of objective responses observed. In track 2, 21 patients per study treatment combination arm were treated in stage 1, and preliminary efficacy was assessed when those patients were evaluable. On the observation of ≥2 responses, stage 2 was initiated with the goal of enrolling an additional 20 patients, for a total of at least 41 patients per study treatment combination arm.

The primary outcome measures were objective response rate (ORR) per investigator using Response Evaluation Criteria in Solid Tumors V.1.1, duration of response (DOR), and progression-free survival (PFS) rate at 24 weeks.²³ Secondary outcomes were safety and tolerability up to 2 years.²³ Immune-mediated adverse events (IMAEs) include subcategories of endocrine events (eg, adrenal disorders, diabetes, pituitary disorders, and thyroid disorders). Overall survival (OS) was a tertiary/exploratory endpoint.

Results

Baseline characteristics

Forty-six patients with aRCC previously treated with IO therapies were included. The median (range) age was 60.5 (36–82) years; most had intermediate IMDC risk (60.9%); most were Caucasian (93.5%), and men (80.4%; online supplemental table 1).

All patients received previous anti-PD-1 or anti-PD-L1 therapy. No patients had been treated with anti-CTLA-4 therapy or with anti-CTLA-4 therapy in combination with anti-PD-1/PD-L1 therapy (per inclusion criteria). Approximately 50% of the patients received three or more systemic therapies before enrollment.

Treatment exposure, duration, and patient disposition

The median cumulative duration of therapy, including the combination and monotherapy phases, was 6.4 months; no patients remained on treatment as of the database lock. The median number (range) of nivolumab doses received overall was four (1–26), and four (1–4) for ipilimumab. Of the 46 patients who discontinued study therapy, disease progression (71.7%) was the most common reason for discontinuation. Eleven of the 46 patients in track 2 were previously enrolled in other FRACTION-RCC tracks (either 1 or 2); after progressing on treatment with nivolumab plus ipilimumab, four were enrolled in another track 2 arm.

Objective response rate and duration of response

ORR was assessed in all 46 patients included in this arm of track 2. After a median follow-up (range) of 33.8 (24.1–45.2) months, the ORR (95% CI) in the entire population (N=46) was 17.4% (7.8 to 31.4), with eight (17.4%) partial responders; table 1.

Table 1

Objective response rate

	Nivolumab plus ipilimumab (N=46)
All treated patients
Objective response rate (95% CI), %	17.4 (7.8 to 31.4)
Disease control rate (95% CI), %*	58.7 (43.2 to 73.0)
Best overall response, n (%)
Complete response	0
Partial response	8 (17.4)
Stable disease	19 (41.3)
Progressive disease	14 (30.4)
Not evaluable/available†	5 (10.9)
Patients with measurable tumor PD-L1 expression
Objective response rate (95% CI), %
PD-L1 ≥1%	12.5 (0.3 to 52.7)
PD-L1 <1%	14.3 (3.0 to 36.3)

*Proportion of patients with a best overall response of complete response, partial response, or stable disease.

†Patients were considered not evaluable or available if either no imaging/measurement was done at a specific time point or if only a subset of lesion measurements were done at an assessment.

PD-L1, programmed death ligand 1.

Most patients achieved a best overall response (BOR) of stable disease (19; 41.3%) or progressive disease (14; 30.4%); five patients (10.9%) were not evaluable or available. Among patients with baseline tumor PD-L1 expression ≥1% versus <1%, the ORR was 12.5% vs 14.3%, respectively.

The best change from baseline in target lesion tumor burden was evaluated in all patients with a baseline and at least one postbaseline assessment (n=38). Of these, 17 patients (44.7%) had a decrease in target lesion tumor burden; 10 had a decrease of ≥30% in target lesion tumor burden and 4 had a decrease of ≥75%, whereas 7 had an increase of ≥20%. The median time to response (range) was 2.9 (1.5–12.7) months and the median DOR (range) was 16.4 (2.1+ to 27.0+) months. Among the eight patients who responded, five (62.5%) had an ongoing response.

Characterization of partial responders

The eight responders received a range of one to eight prior therapies before enrollment; most (6/8; 75%) received either nivolumab monotherapy or nivolumab-based combination therapy as the most recent prior IO (table 2).

Table 2

Characteristics of patients with a response to nivolumab plus ipilimumab* † ‡

Patient	Age, years	Sex	KPS score	No. of prior therapies§	Most recent prior IO therapy¶	Most recent prior therapy¶	BOR on most recent prior IO	Time on NIVO+IPI, months	Time to subsequent therapy, months** ††
1	Mid-70s	M	80	3	NIVO monotherapy	NIVO monotherapy	PD	23.1	25.5
2	Early 50s	M	90	2	NIVO monotherapy	NIVO monotherapy	SD	2.1	–
3	Early 80s	M	80	2	NIVO monotherapy	NIVO monotherapy	SD	5.3	–
4	Late 60s	M	80	8	NIVO+anti-LAG-3 antibody	NIVO+anti-LAG-3 antibody	SD	19.4	–
5	Late 70s	M	80	8	NIVO+anti-LAG-3 antibody	NIVO+anti-LAG-3 antibody	PD	6.2	4.6
6	Late 40s	F	70	1	NIVO+anti-LAG-3 antibody	NIVO+anti-LAG-3 antibody	PD	14.5	9.9
7	Early 70s	M	80	3	Avelumab/axitinib	TAK-228	PR	5.4	–
8	Early 50s	M	100	2	Atezolizumab/ bevacizumab	Cabozantinib	PR	23.8	–

*All patients had clear cell histology and all had metastatic disease at study entry.

†All patients had a nephrectomy.

‡All patients were Caucasian.

§The number of prior therapies includes patients who received prior IO therapy in a different FRACTION cohort.

¶The regimen setting for all prior regimens in all patients was metastatic disease.

**Dash indicates that at the time of the database lock, subsequent therapy was not initiated, documented, or was unable to be determined.

††Refers to subsequent therapy after progression or lack of response to nivolumab plus ipilimumab.

BOR, best overall response; IO, immuno-oncology; IPI, ipilimumab; KPS, Karnofsky performance status; LAG-3, lymphocyte-activation gene 3; NIVO, nivolumab; PD, progressive disease; PR, partial response; SD, stable disease.

The best response on prior IO in responders was progressive disease in three, stable disease in three, and partial response in two patients. BOR to nivolumab plus ipilimumab is also presented by BOR on most recent prior IO therapy in online supplemental table 2.

Of all responders, five patients achieved ≥50%, four of whom achieved >75% decrease in tumor burden (online supplemental figure 3).

Progression-free survival and overall survival

All 46 patients were included in the analyses for PFS and OS, including the five patients who were not evaluable for ORR. These five patients were either censored or died. Thirty-one of the 46 (67.4%) patients experienced disease progression on treatment. Median PFS (95% CI) was 3.7 (2.0 to 7.3) months (figure 1A) with 43.2% PFS rate at 6 months. Among the 19 patients with a BOR of stable disease, the median PFS (95% CI) was 7.2 (3.4 to 11.0) months; 12 of the 19 (63.2%) experienced a progression event overall. In these patients, the PFS rate (95% CI) at 6 months was 54.5% (27.4 to 75.3).

Figure 1. Kaplan-Meier plots of progression-free survival (PFS; A) and overall survival (OS; B). NE, not estimable; NIVO+IPI, nivolumab plus ipilimumab.

Twenty-three of 46 (50.0%) patients died of any cause. Median OS (95% CI) was 23.8 (13.2 to not estimable) months (figure 1B) with 66.6% OS probability at 12 months.

Safety

Of the 46 patients, any-grade treatment-related adverse events (AEs) were reported in 36 (78.3%) patients and grade 3–4 treatment-related AEs were reported in 13 (28.3%) patients (online supplemental table 3). Treatment-related AEs leading to discontinuation occurred in four (8.7%) patients, three (6.5%) of which were categorized as grade 3–4. Five patients (10.9%) had any-grade treatment-related serious AEs and three (6.5%) experienced a grade 3–4 serious treatment-related AE. No grade 5 treatment-related AEs were reported. A total of 32 any-grade IMAEs for nivolumab plus ipilimumab were reported in 23 (50.0%) of the 46 treated patients, with 7 (15.2%) patients reporting grade 3–4 IMAEs (online supplemental table 4). No grade 5 IMAEs were reported. Seven (15.2%) of the 46 treated patients required ≥40 mg prednisone daily or equivalent to manage any-grade IMAEs, as did 5 patients for grade 3–4 IMAEs.

Discussion

The results from FRACTION-RCC track 2 contribute to the knowledge on optimal sequencing of IO therapies for patients with aRCC. Given the evolution of the use of front-line combinations of oral multikinase inhibitors with a single-agent IO, the appreciation that a subset of patients who progress on front-line therapy including a single anti-PD-1 agent may still achieve durable remissions with combination IO is important.

Several studies have evaluated a sequential approach in which nivolumab monotherapy is administered first, and then a response-adaptive strategy is used to determine which patients are eligible for combination treatment with nivolumab plus ipilimumab.^17–21 In OMNIVORE (included all IMDC risk patients), HCRN GU16-260 (included all IMDC risk patients), and TITAN-RCC (included only intermediate/poor-risk patients), all patients initiated nivolumab monotherapy; those who progressed on monotherapy were then eligible for treatment with nivolumab plus ipilimumab.^17–21 In aggregate, the studies generally suggest that the sequential approach was not always feasible, and though the ORR was improved with combination therapy, efficacy overall may be limited compared with initial combination therapy with PD-1/CTLA-4 therapy.^17–21

Despite the lower response rate (17.4%) observed in the IO-pretreated patients in FRACTION-RCC versus the response rate (39%) reported in the treatment-naïve patients in CheckMate 214, the outcomes are encouraging.¹⁴ In FRACTION-RCC, the results showed that patients who had already progressed on IO therapy still derived clinical benefit, some with durable responses (median DOR 16.4 months), suggesting that this combination is an option in patients whose tumors progress on prior PD-1/PD-L1 inhibitors. Of note, it is not possible to discern the individual contribution of each drug, and it is possible that most of the efficacy could come from the CTLA-4 inhibitor ipilimumab as the patients were not exposed to it previously.

In the full cohort of 46 patients, of those who achieved a partial response (n=8), three received treatment with nivolumab plus an anti-LAG-3 agent before enrollment in track 2. Of the 46 patients who did not achieve a response (n=38), 7 were treated with nivolumab plus an anti-LAG-3 drug in a prior line of therapy. Of these seven patients, two maintained stable disease and one was not evaluable (due to early discontinuation) after switching to nivolumab plus ipilimumab, and four had progressive disease.

The FRACTION-RCC adaptive approach allowed for an efficient method for optimizing treatment sequencing in previously treated patients with a high unmet need.

The findings show ongoing clinical benefits among some patients receiving nivolumab plus ipilimumab after progression on previous IO therapies, with a manageable safety profile that was consistent with previously published safety outcomes.

The FRACTION study platform is expected to support future translational research by contributing to the understanding of key pathways and biomarkers associated with treatment resistance and mechanisms of action of therapies. Biomarkers such as PD-L1, LAG-3, and CTLA-4 will inform future studies and clinical practice about the expression of checkpoints in the immune pathway and their implications on response to treatment and treatment sequencing. Additionally, immune markers such as Ki-67, CD8+, MPO, and FOXP3 may provide insights into mechanisms of action of and resistance to therapies.

We thank the patients and families who made this study possible; the clinical study teams; Dako, an Agilent Technologies company, for collaborative development of the PD-L1 IHC 28-8 pharmDx assay (Santa Clara, California); and Bristol Myers Squibb (Princeton, New Jersey) and Ono Pharmaceutical Company (Osaka, Japan). The study was supported by Bristol Myers Squibb. All authors contributed to and approved the presentation; writing and editorial assistance were provided by Jenny Reinhold, PharmD, of Parexel, funded by Bristol Myers Squibb.

Data availability statement

Data are available upon reasonable request. Bristol Myers Squibb’s policy on data sharing may be found at https://www.bms.com/researchers-and-partners/independent-research/data-sharing-request-process.html.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study was conducted in accordance with Good Clinical Practice, as defined by the International Council for Harmonisation in accordance with the ethical principles underlying European Union Directive 2001/20/EC United States Code of Federal Regulations, Title 21, Part 50 (21CFR50), and applicable local requirements. Participants gave informed consent to participate in the study before taking part.

Footnote

Twitter @DrChoueiri

Contributors TKC: Conceptualization, investigation, review and editing of all drafts of the manuscript; HK: Investigation, review and editing of the draft; SG: Investigation, review and editing of the draft; SST: Investigation, review and editing of the draft; TMK: Investigation, review and editing of the draft; RP: Investigation, review and editing of the draft; SN: Investigation, review and editing of the draft; GP: Investigation, review and editing of the draft; MAC: Investigation, review and editing of the draft; VC: Investigation, review and editing of the draft; EF: Investigation, review and editing of the draft; C-HL: Investigation, review and editing of the draft; SJH: Investigation, review and editing of the draft; WHM: Investigation, review and editing of the draft; SSS: Conception and design, data acquisition, data analysis, review and editing of the draft; C-WL: Conception and design, data acquisition, data analysis, review and editing of the draft; HD: Conception and design, data acquisition, data analysis, review and editing of the draft; PB: Conception and design, data acquisition, data analysis, review and editing of the draft; RJM: Conceptualization, investigation, review and editing of the draft; BE: Conceptualization, investigation, review and editing of all drafts of the manuscript.

Funding This work was supported by Bristol Myers Squibb. Patients treated at Memorial Sloan Kettering Cancer Center were supported in part by Memorial Sloan Kettering Cancer Center Support Grant/Core Grant (P30 CA008748).

Competing interests TKC reports consulting or advisory board fees, honoraria, and research grants from AstraZeneca, Aravive, AVEO Pharmaceuticals, Bayer, Bristol Myers Squibb (BMS), Calithera, Circle Pharma, Eisai, EMD Serono, Exelixis, GlaxoSmithKline, IQVIA, Infinity, Ipsen, Janssen, Kanaph, Lilly, Merck, NiKang, Nuscan, Novartis, Pfizer, Roche, Sanofi/Aventis, Surface Oncology, Takeda, Tempest, Up-To-Date, and CME events (Peerview, OncLive, MJH and others), outside the submitted work. Institutional patents filed on molecular mutations and immunotherapy response/toxicity, and circulating tumor DNA. Equity holdings: Tempest, Pionyr, Osel, and Precede Bio. Committees: NCCN, GU Steering Committee, ASCO/ESMO, ACCRU, and KidneyCan. Medical writing and editorial assistance support may have been funded by communications companies in part. Mentored several non-US citizens on research projects with potential funding (in part) from non-US sources/foreign components. The institution (Dana-Farber Cancer Institute) may have received additional independent funding of drug companies or/and royalties potentially involved in research around the subject matter. Dr Choueiri is supported in part by the Dana-Farber/Harvard Cancer Center Kidney SPORE and Program, the Kohlberg Chair at Harvard Medical School and the Trust Family, Michael Brigham, Pan-Mass Challenge, and Loker Pinard Funds for Kidney Cancer Research at DFCI. CV provided upon request for scope of clinical practice and research. HK reports institutional research grant funding from Apexigen, BMS, and Merck; personal fees from Array Biopharma, BMS, Calithera Biosciences, Celldex, ChemoCentryx, Clinigen, Elevate Bio, GI reviewers, GigaGen, Immunocore, Instil Bio, Iovance, Merck, Shionogi, and Signatera. SG reports consulting or advisory role from BMS, Bayer, Pfizer, Exelixis, Corvus Pharmaceuticals, Sanofi/Genzyme, EMD Serono, Seattle Genetics/Astellas, Eisai, Merck, AVEO Pharmaceuticals, and QED Therapeutics; and research funding (institutional) from Pfizer, Merck, Agensys, Novartis, BMS, Bayer, Eisai, Seattle Genetics/Astellas, Calithera Biosciences, Immunomedics, Corvus Pharmaceuticals, and Surface Oncology. SST reports consulting or advisory board fees from Merck, Intellisphere LLC, Natera, BMS, and Exelixis; patent pending (Fred Hutchinson Cancer Center); and research funding (institutional) from Genentech, BMS, Merck Sharp & Dohme, Calithera Biosciences, Pfizer, Jounce Therapeutics, Nektar, Exelixis, and Clinigen Group. TMK has nothing to disclose. RP reports consulting fees from Karyopharm Therapeutics and BiolineRx. SN has nothing to disclose. GP reports advisory board fees from AstraZeneca, BMS, Ipsen, Janssen, Merck Sharp & Dohme, Novartis, and Pfizer. MAC reports consulting or advisory fees from Astellas Pharma, AbbVie, Roche/Genentech, Pfizer, and Foundation Medicine; and research funding (institutional) from BMS, AstraZeneca, Pfizer, and Gilead Science. VC reports consulting or speakers’ bureau fees from Ipsen, Eisai, Merck, AstraZeneca, Pfizer, Novartis, BMS, Astellas and Janssen. EF has nothing to disclose. C-HL reports research funding (institutional) from BMS, Calithera Biosciences, Eisai, Eli Lilly, Exelixis, Merck, and Pfizer; consulting fees from Amgen, BMS, Exelixis, Eisai, Merck, Pfizer, and EMD Serono; and honoraria from AiCME, Intellisphere, and Research to Practice. SJH reports compensation for advisory boards and speakers’ bureaus from Astellas, AstraZeneca, Bayer, BMS, Eisai, Exelixis, Janssen, Ipsen, Merck, Roche, Sanofi, Seagen, and SignalChem; institutional research or grant funding from Astellas, AstraZeneca, Ayala, Bayer, BMS, Eisai, Exelixis, Janssen, Ipsen, Merck, Roche, Sanofi, Seagen, and SignalChem. WHM reports consulting or advisory board fees from BMS, Merck, Roche, Novartis, GlaxoSmithKline, and Amgen; honoraria from BMS, Roche, Novartis, and GlaxoSmithKline; and research funding (institutional) from Merck, BMS, Novartis, GlaxoSmithKline, Roche, AstraZeneca, MethylGene, and MedIm. SSS, C-WL, HD, and PB are employed by and has stock ownership in BMS. RJM reports advisory board fees from AstraZeneca, AVEO Pharmaceuticals, Eisai, EMD Serono, Exelixis, Genentech/Roche, Incyte, Lilly Oncology, Merck, Novartis, and Pfizer; and research funding (institutional) from BMS, Eisai, Exelixis, Genentech/Roche, Merck, and Pfizer. BE reports research funding (institutional) from BMS; consulting fees from Pfizer, BMS, Ipsen, AVEO Pharmaceuticals, Oncorena, and Eisai; honoraria from Pfizer, BMS, Ipsen, Oncorena, and Eisai; and travel accommodations and expenses from BMS, Ipsen, and Merck Sharp & Dohme.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

References

¹ Gulati S, Labaki C, Karachaliou GS, et al. First-line treatments for metastatic clear cell renal cell carcinoma: an ever-enlarging landscape. Oncologist 2022; 27: 125–34. doi:10.1093/oncolo/oyab056 http://www.ncbi.nlm.nih.gov/pubmed/35641205

² Schmidt AL, Tabakin AL, Singer EA, et al. Next steps: sequencing therapies in metastatic kidney cancer in the contemporary era. Am Soc Clin Oncol Educ Book 2021; 41: 187–97. doi:10.1200/EDBK_320785 http://www.ncbi.nlm.nih.gov/pubmed/33793313

³ National Comprehensive Cancer Network (NCCN) Guidelines. Kidney cancer. v3.2023, 2022.

⁴ Braun DA, Bakouny Z, Hirsch L, et al. Beyond conventional immune-checkpoint inhibition - novel immunotherapies for renal cell carcinoma. Nat Rev Clin Oncol 2021; 18: 199–214. doi:10.1038/s41571-020-00455-z http://www.ncbi.nlm.nih.gov/pubmed/33437048

⁵ Choueiri TK, Atkins MB, Bakouny Z, et al. Summary from the first Kidney Cancer Research Summit, September 12-13, 2019: a focus on translational research. J Natl Cancer Inst 2021; 113: 234–43. doi:10.1093/jnci/djaa064 http://www.ncbi.nlm.nih.gov/pubmed/32359162

⁶ Choueiri TK, Motzer RJ. Systemic therapy for metastatic renal-cell carcinoma. N Engl J Med 2017; 376: 354–66. doi:10.1056/NEJMra1601333 http://www.ncbi.nlm.nih.gov/pubmed/28121507

⁷ Ravi P, Bakouny Z, Schmidt A, et al. Novel therapeutic approaches and the evolution of drug development in advanced kidney cancer. Cancer J 2020; 26: 464–70. doi:10.1097/PPO.0000000000000477 http://www.ncbi.nlm.nih.gov/pubmed/32947315

⁸ Van Allen EM, Choueiri TK. Dissecting the immunogenomic biology of cancer for biomarker development. Nat Rev Clin Oncol 2021; 18: 133–4. doi:10.1038/s41571-020-00461-1 http://www.ncbi.nlm.nih.gov/pubmed/33299070

⁹ Resch I, Bruchbacher A, Franke J, et al. Outcome of immune checkpoint inhibitors in metastatic renal cell carcinoma across different treatment lines. ESMO Open 2021; 6: 100122. doi:10.1016/j.esmoop.2021.100122 http://www.ncbi.nlm.nih.gov/pubmed/34217917

¹⁰ Singla N. Rational therapeutic sequencing in metastatic renal cell carcinoma: insights gained from IMmotion150. Eur Urol 2021; 79: 674–5. doi:10.1016/j.eururo.2021.01.043 http://www.ncbi.nlm.nih.gov/pubmed/33608152

¹¹ Vano Y-A, Phan L, Gravis G, et al. Cabozantinib-nivolumab sequence in metastatic renal cell carcinoma: the CABIR study. Int J Cancer 2022; 151: 1335–44. doi:10.1002/ijc.34126 http://www.ncbi.nlm.nih.gov/pubmed/35603906

¹² Motzer RJ, Escudier B, McDermott DF, et al. Nivolumab versus everolimus in advanced renal-cell carcinoma. N Engl J Med 2015; 373: 1803–13. doi:10.1056/NEJMoa1510665 http://www.ncbi.nlm.nih.gov/pubmed/26406148

¹³ Goebell PJ, Ivanyi P, Bedke J, et al. Consensus paper: current state of first- and second-line therapy in advanced clear-cell renal cell carcinoma. Future Oncol 2020; 16: 2307–28. doi:10.2217/fon-2020-0403 http://www.ncbi.nlm.nih.gov/pubmed/32964728

¹⁴ Motzer RJ, Tannir NM, McDermott DF, et al. Nivolumab plus ipilimumab versus sunitinib in advanced renal-cell carcinoma. N Engl J Med 2018; 378: 1277–90. doi:10.1056/NEJMoa1712126 http://www.ncbi.nlm.nih.gov/pubmed/29562145

¹⁵ Kim M-C, Jin Z, Kolb R, et al. Updates on immunotherapy and immune landscape in renal clear cell carcinoma. Cancers (Basel) 2021; 13: 5856. doi:10.3390/cancers13225856 http://www.ncbi.nlm.nih.gov/pubmed/34831009

¹⁶ Gul A, Stewart TF, Mantia CM, et al. Salvage ipilimumab and nivolumab in patients with metastatic renal cell carcinoma after prior immune checkpoint inhibitors. J Clin Oncol 2020; 38: 3088–94. doi:10.1200/JCO.19.03315 http://www.ncbi.nlm.nih.gov/pubmed/32491962

¹⁷ Atkins MB, Jegede O, Haas NB, et al. Phase II study of nivolumab and salvage nivolumab + ipilimumab in treatment-naïve patients (PTS) with advanced renal cell carcinoma (RCC) (HCRN GU16-260). J Clin Oncol 2020; 38: 5006. doi:10.1200/JCO.2020.38.15_suppl.5006

¹⁸ Atkins MB, Jegede O, Haas NB, et al. Phase II study of nivolumab and salvage nivolumab + ipilimumab in treatment-naïve patients (PTS) with advanced clear cell renal cell (HCRN GU16-260-Cohort a): final report. J Clin OncolJCO 2022; 40: 288. doi:10.1200/JCO.2022.40.6_suppl.288

¹⁹ Grimm M-O, Schmidinger M, Duran Martinez I, et al. Tailored immunotherapy approach with nivolumab in advanced renal cell carcinoma (TITAN-RCC). Annals of Oncology 2019; 30: v892. doi:10.1093/annonc/mdz394.051

²⁰ McKay RR, McGregor BA, Xie W, et al. Optimized management of nivolumab and ipilimumab in advanced renal cell carcinoma: a response-based phase II study (OMNIVORE). J Clin Oncol 2020; 38: 4240–8. doi:10.1200/JCO.20.02295 http://www.ncbi.nlm.nih.gov/pubmed/33108238

²¹ Grimm M-O, Esteban E, Barthélémy P, et al. Efficacy of nivolumab/ipilimumab in patients with initial or late progression with nivolumab: updated analysis of a tailored approach in advanced renal cell carcinoma (TITAN-RCC). J Clin Oncol 2021; 39: 4576. doi:10.1200/JCO.2021.39.15_suppl.4576

²² Ravi P, Mantia C, Su C, et al. Use of immune checkpoint inhibitors (ICIs) after prior ICI in metastatic renal cell carcinoma (mRCC): results from a multicenter collaboration. J Clin Oncol 2020; 38: 5077. doi:10.1200/JCO.2020.38.15_suppl.5077

²³ Simonsen KL, Fracasso PM, Bernstein SH, et al. The fast real-time assessment of combination therapies in Immuno-ONcology (fraction) program: innovative, high-throughput clinical screening of immunotherapies. Eur J Cancer 2018; 103: 259–66. doi:10.1016/j.ejca.2018.07.127 http://www.ncbi.nlm.nih.gov/pubmed/30292142