Lenvatinib plus Pembrolizumab or Everolimus for Advanced Renal Cell Carcinoma

BACKGROUND Lenvatinib in combination with pembrolizumab or everolimus has activity against advanced renal cell carcinoma. The efficacy of these regimens as compared with that of sunitinib is unclear.

METHODS In this phase 3 trial, we randomly assigned (in a 1:1:1 ratio) patients with advanced renal cell carcinoma and no previous systemic therapy to receive lenvatinib (20 mg orally once daily) plus pembrolizumab (200 mg intravenously once every 3 weeks), lenvatinib (18 mg orally once daily) plus everolimus (5 mg orally once daily), or sunitinib (50 mg orally once daily, alternating 4 weeks receiving treatment and 2 weeks without treatment). The primary endpoint was progression-free survival, as assessed by an independent review committee in accordance with Response Evaluation Criteria in Solid Tumors, version 1.1. Overall survival and safety were also evaluated.

RESULTS A total of 1069 patients were randomly assigned to receive lenvatinib plus pembrolizumab (355 patients), lenvatinib plus everolimus (357), or sunitinib (357). Progression-free survival was longer with lenvatinib plus pembrolizumab than with sunitinib (median, 23.9 vs. 9.2 months; hazard ratio for disease progression or death, 0.39; 95% confidence interval [CI], 0.32 to 0.49; P<0.001) and was longer with lenvatinib plus everolimus than with sunitinib (median, 14.7 vs. 9.2 months; hazard ratio, 0.65; 95% CI, 0.53 to 0.80; P<0.001). Overall survival was longer with lenvatinib plus pembrolizumab than with sunitinib (hazard ratio for death, 0.66; 95% CI, 0.49 to 0.88; P=0.005) but was not longer with lenvatinib plus everolimus than with sunitinib (hazard ratio, 1.15; 95% CI, 0.88 to 1.50; P=0.30). Grade 3 or higher adverse events emerged or worsened during treatment in 82.4% of the patients who received lenvatinib plus pembrolizumab, 83.1% of those who received lenvatinib plus everolimus, and 71.8% of those who received sunitinib. Grade 3 or higher adverse events occurring in at least 10% of the patients in any group included hypertension, diarrhea, and elevated lipase levels.

CONCLUSIONS Lenvatinib plus pembrolizumab was associated with significantly longer progression-free survival and overall survival than sunitinib. (Funded by Eisai and Merck Sharp and Dohme; CLEAR ClinicalTrials.gov number, NCT02811861)

Authors: Robert Motzer, M.D., Boris Alekseev, M.D., Sun-Young Rha, M.D., Camillo Porta, M.D., Masatoshi Eto, M.D., Thomas Powles, M.D., Viktor Grünwald, M.D., Thomas E. Hutson, M.D., Evgeny Kopyltsov, M.D., María J. Méndez-Vidal, M.D., Vadim Kozlov, M.D., Anna Alyasova, M.D., Sung-Hoo Hong, M.D., Anil Kapoor, M.D., Teresa Alonso Gordoa, M.D., Jaime R. Merchan, M.D., Eric Winquist, M.D., Pablo Maroto, M.D., Jeffrey C. Goh, M.D., Miso Kim, M.D., Howard Gurney, M.B., B.S., Vijay Patel, M.D., Avivit Peer, M.D., Giuseppe Procopio, M.D., Toshio Takagi, M.D., Bohuslav Melichar, M.D., Frederic Rolland, M.D., Ugo De Giorgi, M.D., Shirley Wong, M.D., Jens Bedke, M.D., Manuela Schmidinger, M.D., Corina E. Dutcus, M.D., Alan D. Smith, M.D., Lea Dutta, M.D., Kalgi Mody, M.D., Rodolfo F. Perini, M.D., Dongyuan Xing, Ph.D., and Toni K. Choueiri, M.D. for the CLEAR Trial Investigators*

From Memorial Sloan Kettering Cancer Center, New York (R.M.); P. Hertsen Moscow Oncology Research Institute, Moscow (B.A.), the State Institution of Health Care Regional Clinical Oncology Dispensary, Omsk (E.K.), the State Budgetary Health Care Institution Novosibirsk Regional Clinical Oncology Dispensary, Novosibirsk (V.K.), and Prevoljskiy Region Medical Center, Novgorod (A.A.) — all in Russia; Yonsei Cancer Center, Yonsei University Health System (S.Y.R.), Seoul St. Mary’s Hospital, Catholic University of Korea (S.-H.H.), and Seoul National University Hospital (M.K.), Seoul, South Korea; San Matteo University Hospital Foundation, Pavia (C.P.), Istituto Nazionale dei Tumori IRCCS, Milan (G.P.), and Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Meldola (U.D.G.) — all in Italy; Kyushu University, Fukuoka (M.E.), and Tokyo Women’s Medical University, Tokyo (T.T.) — both in Japan; the Royal Free NHS Trust, London (T.P.), and Eisai, Hatfield (A.D.S.) — both in the United Kingdom; University Hospital Essen, Essen (V.G.), and the University of Tübingen, Tübingen (J.B.) — both in Germany; Texas Oncology, Dallas (T.E.H.); Maimonides Institute for Biomedical Research of Cordoba Hospital Universitario Reina Sofía, Medical Oncology Department, Córdoba (M.J.M.-V.), Hospital Universitario Ramón y Cajal, Madrid (T.A.G.), and Hospital de la Santa Creu i Sant Pau, Barcelona (P.M.) — all in Spain; McMaster University, Hamilton (A.K.), and Western University, London (E.W.) — both in Ontario, Canada; the University of Miami Sylvester Comprehensive Cancer Center, Miami (J.R.M.), and Florida Cancer Specialists, Gainesville (V.P.); ICON Research, South Brisbane, and University of Queensland, St. Lucia, QLD (J.C.G.), Macquarie University, Sydney (H.G.), and Western Health, Melbourne, VIC (S.W.) — all in Australia; Rambam Health Care Campus, Haifa, Israel (A.P.); Palacky University and University Hospital Olomouc, Olomouc, Czech Republic (B.M.); Centre René Gauducheau, Saint Herblain, France (F.R.); the Department of Urology, Medical University of Vienna, Vienna (M.S.); Eisai, Woodcliff Lake (C.E.D., L.D., K.M., D.X.), and Merck, Kenilworth (R.F.P.) — both in New Jersey; and Dana–Farber Cancer Institute, Boston (T.K.C.).

Source: Motzer R, Alekseev B, Sun-Young Rha et al. "Lenvatinib plus Pembrolizumab or Everolimus for Advanced Renal Cell Carcinoma." The New England Journal of Medicine. 2021. 10.1056/NEJMoa2035716.
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