Medical treatment of metastatic renal cell carcinoma (mrcc) in the elderly ( 65y): Position of a SIOG Taskforce

Medical treatment of metastatic renal cell carcinoma (mrcc) in the elderly ( 65y): Position of a SIOG Taskforce

Medical treatment of metastatic RCC in the elderly ( 65y): Members of the SIOG Taskforce Joaquim Bellmunt (University hospital del Mar, Spain) Sylvie Negrier (Centre Leon Berard, France) Bernard Escudier (Gustave Roussy Institute, France) Ahmad Awada (Jules Bordet Institute, Belgium) Matti Aapro (Clinique de Genolier, Switzerland)

Considerations in the management of mrcc in the elderly patients (1) The incidence of RCC increases with age The management of an individual patient with RCC should depend on biological rather than chronological age Elderly population is more likely to include patients with poor PS, significant co-morbidities, enhancement of surgical (nephrectomy) morbidity and mortality and a reduce tolerance to medical therapy

Considerations in the management of mrcc in the elderly patients (2) Conditions such as hypertension, cardiovascular disease, diabetes and gastrointestinal disorders are frequent in elderly pts Co-medications may interact with systemic therapy of RCC and so increasing toxicity, reducing efficacy or both. Psychological acceptance of side effects is variable The impact of low grade side effects may be greater in elderly than in their younger counterparts

Clinical trials of RCC: Limitations to draw strong recommendations on the systemic therapy of elderly patients Retrospective analysis of subgroups of patients Patients who entered into studies might be unrepresentative of the wider population (due to strict eligibility criteria related to PS, biological parameters and co-morbidities) The influence of age and co-morbidities on the efficacy and toxicity of treatments is not reported To date, we have no data from, head to head comparisons of the active agents in RCC

Focus on 3 drugs in view of the availability of clinical data in elderly pts ( 65 y) Sunitinib Sorafenib Temsirolimus

Age characteristics of patients included in clinical trials of RCC Median age (y): 58 (Sorafenib) 62 (Sunitinib) Range of ages (y): 25-35 (youngest) 80-86 (most elderly) % of pts 65 y: 30-37 Cytokines: median age : oldest : 55y 74y

Sinutinib vs IFN : Progression-free survival in subgroups, according to baseline factors (independent central review)

Sunitinib Expanded Access Study Efficacy data, subgroups Brain mets Nonclear cell PS 2 >65yrs n 182 276 308 729 Median FU (mos) 5.3 6.5 4.3 6.9 Response rate 7.1% 5.4% 4.2% 8.1% Clinical benefit 39.5% 47.0% 32.4% 52.1%

TARGETs: sorafenib PFS benefit was consistently observed in all sub-groups Sorafenib benefit Placebo benefit Age <65 years Age 65 years Low MSKCC score Intermediate MSKCC score No prior IL-2/IFN Prior IL-2/IFN Metastasis in lung at baseline Metastasis in liver at baseline Time from diagnosis 1.5 years Time from diagnosis >1.5 years 0 0.5 1.0 1.5 Hazard ratio MSKCC = Memorial-Sloan Kettering Cancer Center IL-2 = interleukin; IFN = interferon Escudier B, et al. ECCO 2005, Paris, France

Best tumour response* Clinical benefit achieved in ~85% of patients <65 years 65 years Best response (RECIST) Sorafenib n=305 a n, % Placebo n=329 b n, % Sorafenib n=146 c n, % Placebo n=123 d n, % CR 1 (<1) PR 26 (9) 5 (2) 17 (12) 3 (2) SD 226 (74) 173 (53) 107 (73) 66 (54) PD 41 (13) 124 (38) 15 (10) 43 (35) Clinical Benefit (CR + PR + SD) 83% 86% Clinical benefit was observed in ~85% of patients receiving sorafenib in patients aged <65 and 65 years TARGETs Age Subgroup Analysis

Progression-free survival Sorafenib benefit consistent across subgroups Sorafenib consistently improved median PFS 2-fold versus placebo irrespective of age subgroup PFS by subgroup demonstrated similar clinical benefit with sorafenib in the <65 and 65 years subgroup TARGETs Age Subgroup Analysis CI, confidence interval; HR, hazard ratio; MSKCC, Memorial Sloan-Kettering Cancer Center; PFS, progression-free survival

Incidence of treatment-related adverse events* is similar across sorafenib age subgroups <65 years 65 years Adverse event, n (%) Any event grade 2 grade 3 Hypertension grade 2 grade 3 Fatigue grade 2 grade 3 Diarrhea grade 2 grade 3 Hand foot skin reaction grade 2 grade 3 Haemoglobin grade 2 grade 3 *In 2% of patients by age subgroup Sorafenib n=305 253 (83) 67 (22) 44 (14) 9 (3) 71 (23) 5 (2) 113 (37) 6 (2) 93 (31) 15 (5) 6 (2) 4 (1) Placebo n=329 173 (53) 21 (6) 5 (2) 1 (<1) 56 (17) 5 (2) 32 (10) 2 (1) 20 (6) 0 (0) 9 (3) 6 (2) Sorafenib n=146 122 (84) 33 (23) 13 (9) 1 (1) 38 (26) 6 (4) 57 (39) 4 (3) 37 (25) 10 (7) 2 (1) 2 (1) Placebo n=123 56 (46) 5 (4) 0 (0) 0 (0) 14 (11) 0 (0) 10 (8) 1 (1) 8 (7) 0 (0) 2 (2) 1 (1) TARGETs Age Subgroup Analysis

Health-related quality of life By Cycle 5, the majority of sorafenibtreated patients reported stable or better symptom response than placebo FKSI Sorafenib improved HRQOL: at 18 and 24 weeks, more sorafenib-treated patients had stable or improved total FKSI scores from baseline compared with placebo in the <65 and 65 years subgroups FKSI score TARGETs Age Subgroup Analysis FKSI, Functional Assessment of Cancer Therapy-Kidney Symptom Index; HRQOL, health-related quality of life; PRO, patient-reported outcome

Time to deterioration in health status Sorafenib significantly delayed the time to self-reported health status deterioration for both age groups compared with placebo Median time to health status deterioration was a 4-point change in FKSI or FACT-G total score, disease progression, or death TARGETs Age Subgroup Analysis

Phase III Temsirolimus: OS Hazard Ratios in Patient Subgroups Subgroup Patients, n Hazard Ratio (95% CI) Histology Clear-cell 339 Other 73 Age <65 yr 287 65 yr 129 Prognostic Risk Intermediate 115 Poor 301 0 0.5 1.0 1.5 2.0 Temsirolimus Better IFN-α Better Adapted from Dutcher J et al. Presented at ASCO Annual Meeting; June 1-5, 2007; Chicago, IL.

Phase III Temsirolimus: OS and PFS by Age* Among pts <65y, median OS and PFS were greater for TEMSR than for IFN Age Group n (%) Overall Survival (P=0.0201) b IFN (n=207) TEMSR 25 mg (n=209) TEMSR vs IFN Median mos n (%) Median mos Hazard Ratio a (95% CI) <65y 142 (68.6) 6.9 145 (69.4) 12.0 0.67 (0.52, 0.87) 65y 65 (31.4) 8.3 64 (30.6) 8.6 1.15 (0.78, 1.68) Progression-free Survival, Independent [Investigator] Assessment (P=.0848 [P=.1940]) b <65y 142 (68.6) 3.1 [1.9] 145 (69.4) 5.9 [3.8] 0.69 (0.54, 0.88) [0.68 (0.54, 0.87)] 65y 65 (31.4) 3.5 [1.9] 64 (30.6) 3.7 [3.8] 1.00 (0.7, 1.44) [0.92 (0.64, 1.31)] b Test of interaction between treatment and variable, based on unstratified Cox proportional hazard model. *ITT population. Adapted from Dutcher J et al. Presented at ASCO Annual Meeting; June 1-5, 2007; Chicago, IL.

Main toxicities Toxicity Nexavar Sutent Avastin Fatigue + +++ + Diarrhoea +++ ++ 0 Stomatitis + +++ + Skin ++ + 0 Hand foot skin reaction +++ + 0 Hair + (alopecia) + (colour change) 0 Hypertension + +++ +

Main toxicities (cont d) Toxicity Nexavar Sutent Avastin Neutropenia 0 ++ + Thrombocytopenia 0 ++ 0 Anaemia 0 + 0 Proteinuria 0 0 + Hypophosphataemia + + 0

Phase III Temsirolimus: Percentage of Patients With Selected Grade 3 or 4 AEs ( 5%) by Age* There does not appear to be any age-related difference in adverse events Adverse Event IFN (n=137) <65y 65y TEMSR 25mg (n=145) IFN (n=63) TEMSR 25mg (n=63) Any AE 79 68 79 71 Asthenia 23 10 33 14 Dyspnea 6 8 6 10 Anorexia 4 2 5 5 Nausea 3 3 10 2 Fever 3 1 5 0 Confusion 2 0 6 0 Myasthenia 0 0 5 0 Hematologic and Laboratory IFN (n=137) <65y 65y TEMSR 25mg (n=145) IFN (n=63) TEMSR 25mg (n=63) Anemia 24 20 16 19 Neutropenia 7 3 10 2 Increased AST 5 2 2 0 Lymphopenia 4 3 10 8 Hypocalcemia 3 1 5 2 Hyperglycemia 2 10 0 13 Hypophosphatemia 1 6 0 3 Hyperlipidemia 1 6 2 0 *ITT population. Adapted from Dutcher J et al. Presented at ASCO Annual Meeting; June 1-5, 2007; Chicago, IL.

Conclusions of the SIOG task force (1) No meaningful data are available for patients 85 years In general, PFS and OS benefits seen in mrcc pts 65 y are similar to those in their younger conterparts The frequency of main toxicities in elderly pts is no greater than in younger pts, although such toxicities may have greater impact on the quality of life (not well studied)

Conclusions of the SIOG task force (2) When considering the most appropriate drug to use in a particular patient, the toxicity profiles of the individual targeted agents and any implications for specific co-morbid conditions/risk of drug interaction should be taken into account It would be appropriate to monitor patients for thyroid and cardiac dysfunction, hypertension, loss of glycaemic control, GI disorders and to assess regularly the risk of drug interactions