Oncology Pulsepoint: How Updated Immunotherapy Guidelines are Changing Renal Cell Carcinoma Care

In an interview with Pharmacy Times, Angie Maynard, PharmD, discussed key updates to the Society for Immunotherapy of Cancer clinical practice guidelines for immunotherapy in renal cell carcinoma, with a primary focus on clear cell renal cell carcinoma.

Maynard explained that one of the most significant changes is the expanded role of immunotherapy in earlier-stage disease. Adjuvant pembrolizumab may now be considered for certain patients with intermediate-high-risk or high-risk disease following nephrectomy, as well as select patients with metastatic disease who have been resected to no evidence of disease. Treatment should generally begin within 3 to 4 months after surgery and continue for approximately 1 year.

She also reviewed treatment options for metastatic clear cell renal cell carcinoma, including nivolumab plus ipilimumab and combinations of immune checkpoint inhibitors with tyrosine kinase inhibitors, such as pembrolizumab plus axitinib, nivolumab plus cabozantinib, and pembrolizumab plus lenvatinib. Because these regimens have not been compared directly in head-to-head trials, treatment selection should be individualized according to disease characteristics, comorbidities, toxicity profiles, and patient preferences.

From a pharmacy perspective, Maynard emphasized the importance of monitoring for overlapping toxicities associated with immune checkpoint inhibitors and tyrosine kinase inhibitors. Potential adverse effects include hypertension, diarrhea, fatigue, hand-foot reactions, thyroid or endocrine dysfunction, skin changes, and cardiac complications. Pharmacists should also assess concomitant medications for possible drug interactions, particularly with agents metabolized through CYP3A4.

Maynard noted that dose interruptions and reductions are common and should not automatically be viewed as treatment failure. Pharmacists play an important role in educating patients about what to expect, recognizing and managing toxicities early, and helping patients remain on therapy. Her central takeaway was that pharmacists should understand how the pivotal trials administered these regimens and apply that knowledge to monitoring, counseling, and supportive care.