Currently the goal of mRCC treatment strategy is represented by the correct use of the approved drugs in a sequential algorithm [
26,
27]. Axitinib is licensed in Italy for the treatment of mRCC patients only after failure of sunitinib or cytokines therapy. We report herein the retrospective data of axitinib in Italian real-life practice for mRCC: despite our population was more “battered” than the one investigated in AXIS trial, our results are consistent with AXIS ones, confirming the efficacy of axitinib in second line treatment [
10,
11], with ORR, mPFS and mOS of 16.6%, 7.14 and 15.5 months, respectively. Fifteen percentage of our study population was over 75 years, normally under-represented in clinical trials [
28]. The elderly patients are usually a frail population with a lower performance status (PS), poor tolerance to medical treatments and multiple co-morbidities [
29]. To date few data are available concerning the use of axitinib in elderly mRCC patients [
30‐
32]. Our results showed no differences in both mPFS [6.4 months (95% CI 4. 95–7.95, p = 0.74)] and mOS [13.0 months (95% CI 5.9–20.15, p = 0.72)] than younger patients. In addition, there was no significant difference in the incidence of AEs or dose reduction, or discontinuation. The efficacy and safety of the VEGF-TKI -VEGF-TKI treatment sequence has been confirmed by various trials, showing a statistically longer mPFS and in some of these mOS too [
10,
11,
26,
33,
34]. Leung et al. indicated axitinib as more appropriate TTs option, compared to sorafenib and pazopanib, in the second line setting; in particular, axitinib is associated with the lowest risk of withdrawal due to adverse events [
35]. In post hoc analysis of the AXIS trial, Escudier et al. evaluated the efficacy of axitinib by response and duration of prior sunitinib or cytokines treatment, showed no statistically significant differences in PFS or OS in responders vs non-responders, although a significantly longer PFS and OS was reported in patients who had received a longer prior cytokines treatment [
36]. On the contrary, our analysis showed that longer previous sunitinib duration (≤ vs > median duration), correlated with a statistically significant difference in mPFS (8.8 vs 6.3 months, p = 0.021), without any difference in mOS (p = 0.151). The same conclusion was reached by Elaidi et al. who showed that patients who remained on first-line TKI treatment between 11 and 22 months benefited from a TKI rechallenge rather than from second-line mTORi (PFS: 9.4 vs 3.9 months, p = 0.003) [
37]. Higher ORR (20–30%) was reported with VEGF-TKI compared to mTORi (≤ 10%), which is supported by our analysis [
38]. Dose titration to 7 or 10 mg bid was feasible in 24% (35/148) of our patients, lower than the axitinib Asian trial (61.5%) [
39] or the AXIS trial (37%) [
10], but higher than other real-world studies (16%) [
21‐
23,
40,
41]. We reported no differences in both mOS (p = 0.115) and mPFS (p = 0.1), in accordance to the phase II study of first-line axitinib [
17,
23] but in contrast to Matias et al. results, in which dose escalation at 2-weeks was associated to better ORR, PFS and TTF, but not OS. Patients with better ECOG PS (0) experienced longer mPFS, 9.08 (p = 0.026) vs 6.2 months and mOS, 27.2 (p = 0.003) vs 10.9 months. Prior nephrectomy significantly correlated with longer mPFS, 7.7 vs 4.4 months (p = 0.001), as well as longer mOS, 18.7 vs 8.2 months, (p = 0.000004). Axitinib at standard dose of 5 mg bid was safe, a dose reduction occurred in 24% (35/148), without any case of discontinuation: the most common AEs of all grades were: fatigue (50.7%), gastro-intestinal disorders (36.5%), hypertension (26.4%), hypothyroidism (18.2%), dysphonia (12.2%), hand-foot syndrome (14.2%) (Table
5). Our data showed a lower incidence of AEs than AXIS trial, the higher incidence of fatigue in our experience, was probably due to the difficulty to distinguish and explain to the patients the difference between fatigue and asthenia. All these results suggest that axitinib treatment is feasible and safe in this unselected real-world population. At univariate analysis hypertension G3 blood pressure elevation (systolic ≥ 160 mmHg and/or diastolic ≥ 100 mmHg) significantly correlated with longer mPFS and mOS compared to G1-G2 or no toxicity (mean PFS 28.8 months, p = 0.017—mean OS 38.15 months, p = 0.017—median survival times not reached for both analysis Table
6,
7). Our data are consistent with other real-world studies [
42,
43] and AXIS trial, suggesting that the development of hypertension during the treatment could be a surrogate of survival in this population. It was interesting to note that the 18% (27/148) of patients enrolled in our study, adopted a modified schedule of sunitinib in first line (2 weeks on 1 week off), without showing any difference in outcomes. These data confirm those of others retrospective studies that evaluated sunitinib alternative schedules, showing a reduction in the AEs and achieving comparable outcomes to the standard schedule [
44‐
46]. The identification of effective prognostic factors in mRCC patients receiving axitinib represents a new challenge. In these series we identified the following independent prognostic indicators: gender (male), DCR upon axitinib and prior sunitinib for PFS, and DCR upon axitinib, Heng score (poor prognosis vs intermediate vs good prognosis) and prior nephrectomy for OS. The sequence TKI–TKI (sunitinib-axitinib) was well tolerated without worsening in side effects, the global mOS was 41.15 months, higher than AXIS trial (33.7 months). The main limitation of our analysis was represented by the small patient numbers, selection bias, the retrospective nature, without centralized data review. Recently the results of three major clinical trials involving nivolumab, cabozantinib, and lenvatinib plus everolimus, showed superior efficacy in terms of response rates (RR) and OS in second-line setting [
47‐
50] and these will change dramatically the therapeutic sequence in second-line setting. To date, there are few data about the best sequential therapeutic algorithm beyond first-line VEGF TKIs, and no head-to-head study between these new drugs and the currently approved agents are ongoing [
51‐
54]. The mTORi everolimus is the only drug tested head-to-head with nivolumab, cabozantinib and lenvatinib plus everolimus, and no data are available with axitinib as comparator. Treatment selection in second line-setting, is based on several factors, including patient health status, contraindications and comorbidities, histologic RCC subtype, safety profiles, and previous treatment. Recently, Bracarda et al. published a Prognostic Factor Analyses from the AXIS Trial, that as well as our data, identified a subgroup of patients who had a long-term benefit with axitinib treatment. Therefore, axitinib could be suitable (post sunitinib) 2nd line treatment option for mRCC selected patients with VEGF-dependent mRCC, favourable/intermediate risk, low tumour burden, and no bone or liver metastases and with long life expectancy [
55]. In the new era of Immunotherapy, are VEGF-TKIs still a valid option for mRCC treatment? The angiogenesis plays a central role in the RCC tumorigenesis and immunogenicity. The prevalence of pro-angiogenic factors over anti-angiogenic signals promotes an immunosuppressive tumor microenvironment, through abnormal tumor vessel formation and dysregulation of various immune cells. Therefore, anti-angiogenic therapy remains the gold standard in selected patients (VEGF-dependent favourable mRCC in all setting) and increases the efficacy of immunotherapy, modulating immune responses, increasing anticancer immune-trafficking and activity, through the regulation of tumor vessels and reducing suppressing cytokines and infiltrating T regs [
54,
56,
57]. Different phase 3 trials evaluated or are evaluating combination of immune checkpoint inhibitors, such as anti PD-1 nivolumab and anti CTLA-4 ipilimumab, or anti PD-1/PDL-1 and VEGFR-TKI in first-line
treatment, with impressive results that will dramatically impact on the choice of the first and second-line treatments (Table
8).
Table 8
Real world trial data comparison
SAX real world | 7.14 | 15.5 | 70.6 |
Spanish real world | 4.4 | 10.8 | 65.7 |
France real world | 8.3, | 16.4, | 72 |
AXIS | 6.5 | 15.2 | 69.3 |