Highlights

As in other cancers and in renal cancer, immunotherapy is very much an all or nothing thing… The patients who benefit can get very profound, very durable benefits, whereas the patients who don’t benefit probably don’t get anything from immunotherapy. I guess the thing we fear the most is not giving immunotherapy to the patient who is going to be that long-term beneficiary, because there’s no test in knowing who that patient is in advance; I think there’s now a fairly strong feeling that everybody should get a try at immune checkpoint inhibitor because the only way of knowing whether it’s going to work is to try it, and if it does work then the benefits can be profound, that durability of response which is really the attraction here, and I think it’s that that’s driven things through. So, in other words when we only had access in the second line
to nivolumab, I think it did drive more patients to get second-line therapy at all, because there was this fear of missing out, if you like, whereas now with the immune checkpoint therapies that are coming into the frontline setting for many patients, I think that that fear is going away.

[Due to the COVID-19 pandemic], we’re quite nervous about using immunotherapy. Not with actually good data to be honest with you, but right now in some patients where we would have previously given upfront combination immunotherapy, we are saying well, we think it’s maybe safer in your case to actually start with a TKI. I suspect, hopefully this is only a temporary aberration… [Reducing unnecessary hospital visits] is one of the drivers at this particular point in history. I think there is also biological concern about actually
the effect of the therapy on the vulnerability of the patient to coronavirus. There is concern that immune checkpoint inhibitors may actually increase the risk of complications from coronavirus, although admittedly there’s not much hard evidence for that yet. I understand there’s actually a trial of nivolumab to treat coronavirus pneumonia going on in France. So, it’s not founded on facts, it’s founded on theory. But generally, we’re trying to avoid unnecessary hospital visits and unnecessary risk to the patients as well.

I used to use quite a lot of [temsirolimus] actually back in the day… It was quite a useful drug for some patients, but we’ve not used that for a long time now. I don’t know of anybody who’s routinely heavy using temsirolimus in the UK at least. Everolimus still has a role, I think actually its main use now is in combination with lenvatinib, but it still has a role in the mono-agent. Having said that, it’s very much been sort of pushed into the fourth line as a mono-agent, and as such is very rarely used because the data to support its efficacy in that fourth line is not very strong. And in any case, a lot of patients at that point in their pathway are just on supportive care alone. So, we are still using it but very, very rarely, except in combination with lenvatinib where we now use it a bit.