Background

Immune-checkpoint inhibitor (ICI) combinations are the recommended first line systemic anti-cancer therapy (SACT) for patients with aRCC. Single agent tyrosine kinase inhibitors (TKIs) are used in patients not eligible or fit for ICIs. The covid-19 pandemic has impacted on the prescribing practices. We review prescription patterns and outcomes for first line SACT in patients with aRCC.

Method

Anonymised data from patients who commenced first line SACT for aRCC in Bristol Oncology Centre between June 2019 and March 2021 were collected from electronic records.

Results

Forty-eight patients were identified. 39.5%, 45.8% and 14.5% were PS 0, 1 and 1/2, respectively. 25%, 52% and 22.9% were favourable, intermediate and poor IMDC risk, respectively. Median follow-up was 10.8 months. Treatments were as follows: 4/48 (8.3%) TKI + ICI, 16/48 (33%) dual ICI, 28/48 (58.3%) TKI alone.  The proportion of patients prescribed TKI or any ICI was similar pre-pandemic (46.4% and 45%, respectively). Treatment wasn’t stopped as a result of the pandemic and no patients developed covid-19 whilst on treatment.

Those who started ICI were younger (median age 63.4 vs 69.0) with a higher proportion intermediate/poor risk (90% vs 64.3%) and PS 0 (45% vs 35.7%). Reasons for commencing TKI (28 patients) include poor PS (7%), co-morbidities (7%) and favourable IMDC risk group (17.9%). 82.1% patients on TKI started with dose reduction.

There was no difference in the median progression-free (PFS; median: NR vs. 13.2m) and overall survival (OS: median NR) for ICI and TKI group. At initial objective staging assessment, clinical benefit rate (CBR) was 80.0% for patients on ICI vs. 64.3% on TKI only.

Gr3 toxicity rates were 25% (5/20; all required hospital admission: hypophysitis (2 patients), colitis, hepatitis and ketoacidosis) and 35.7% (10/28; 4/28 required hospital admission: wound infection, perforated diverticulum, cerebral micro-haemorrhage and generally unwell) and treatment related discontinuation rates were 3/20 (15%) and 5/28 (17.9%) in the ICI and TKI groups, respectively.

Conclusion

Our results revealed that prescription patterns were not altered due to covid-19 and that it was safe to continue SACT during this period. Clinicians should continue to evaluate patients for treatment based on their co-morbidities and preferences.

Impact statement