Advanced renal cell carcinoma: what to do after first line antiangiogenic therapy?

Antiangiogenic therapy is now a standard in first line for metastatic renal cell carcinoma. Among the different options, sunitinib is particularly proposed by most guidelines, as well as a combination of bevacizumab and interferon-alfa. Defining second line therapy after these agents is dependent on indirect data since no phase III trial has specifically addressed that question.

The most relevant data point to everolimus that has been proven to improve PFS with acceptable toxicity compared with best supportive care in a phase III trial. Most studies on the use of antiangiogenic therapies after failure of a first one seem to demonstrate, more than anything else, that the most effective antiangiogenic therapy should be used up front since limited benefit is expected in second line.

This paper presents some relevant data to help recommend the most appropriate second-line therapy. The quality of data on everolimus is sufficient to propose its use for most patients in the second line setting after failure of a vascular endothelial growth factor receptor-tyrosine kinase inhibitor (VEGFR-TKI). Studies on a second line of antiangiogenic therapy demonstrate limited efficacy that does not lead to a recommendation of adequacy for most patients.