Nivolumab plus Ipilimumab versus Sunitinib in Advanced Renal-Cell Carcinoma

Abstract

Background: Nivolumab plus ipilimumab produced objective responses in patients with advanced renal-cell carcinoma in a pilot study. This phase 3 trial compared nivolumab plus ipilimumab with sunitinib for previously untreated clear-cell advanced renal-cell carcinoma.

Methods: We randomly assigned adults in a 1:1 ratio to receive either nivolumab (3 mg per kilogram of body weight) plus ipilimumab (1 mg per kilogram) intravenously every 3 weeks for four doses, followed by nivolumab (3 mg per kilogram) every 2 weeks, or sunitinib (50 mg) orally once daily for 4 weeks (6-week cycle). The coprimary end points were overall survival (alpha level, 0.04), objective response rate (alpha level, 0.001), and progression-free survival (alpha level, 0.009) among patients with intermediate or poor prognostic risk.

Results: A total of 1096 patients were assigned to receive nivolumab plus ipilimumab (550 patients) or sunitinib (546 patients); 425 and 422, respectively, had intermediate or poor risk. At a median follow-up of 25.2 months in intermediate- and poor-risk patients, the 18-month overall survival rate was 75% (95% confidence interval [CI], 70 to 78) with nivolumab plus ipilimumab and 60% (95% CI, 55 to 65) with sunitinib; the median overall survival was not reached with nivolumab plus ipilimumab versus 26.0 months with sunitinib (hazard ratio for death, 0.63; P<0.001). The objective response rate was 42% versus 27% (P<0.001), and the complete response rate was 9% versus 1%. The median progression-free survival was 11.6 months and 8.4 months, respectively (hazard ratio for disease progression or death, 0.82; P=0.03, not significant per the prespecified 0.009 threshold). Treatment-related adverse events occurred in 509 of 547 patients (93%) in the nivolumab-plus-ipilimumab group and 521 of 535 patients (97%) in the sunitinib group; grade 3 or 4 events occurred in 250 patients (46%) and 335 patients (63%), respectively. Treatment-related adverse events leading to discontinuation occurred in 22% and 12% of the patients in the respective groups.

Conclusions: Overall survival and objective response rates were significantly higher with nivolumab plus ipilimumab than with sunitinib among intermediate- and poor-risk patients with previously untreated advanced renal-cell carcinoma. (Funded by Bristol-Myers Squibb and Ono Pharmaceutical; CheckMate 214 ClinicalTrials.gov number, NCT02231749 .).

Figure 1. Overall Survival and Progression-free Survival among IMDC Intermediate- and Poor-Risk Patients

Progression was defined according to the Response Evaluation Criteria in Solid Tumors, version 1.1. For progression-free survival, the between-group difference did not meet the prespecified threshold (P = 0.009) for statistical significance. IMDC denotes International Metastatic Renal Cell Carcinoma Database Consortium, NE not estimable, and NR not reached.

Figure 2. Subgroup Analysis of Overall Survival among IMDC Intermediate- and Poor-Risk Patients

Patients with intermediate risk had an IMDC score of 1 or 2, and those with poor risk had a score of 3 to 6. IMDC risk scores are defined by the number of the following risk factors present: a Karnofsky performance-status score of 70 (on a scale from 0 to 100, with lower scores indicating greater disability; patients with a performance-status score of <70 were excluded from the trial), a time from initial diagnosis to randomization of less than 1 year, a hemoglobin level below the lower limit of the normal range, a corrected serum calcium concentration of more than 10 mg per deciliter (2.5 mmol per liter), an absolute neutrophil count above the upper limit of the normal range, and a platelet count above the upper limit of the normal range. Bone, liver, lung, and lymph-node metastases were not protocol-prespecified subgroups. PD-L1 denotes programmed death ligand 1.

Figure 3. Health-Related Quality of Life in IMDC Intermediate- and Poor-Risk Patients

Scores on the National Comprehensive Cancer Network Functional Assessment of Cancer Therapy–Kidney Symptom Index (FKSI-19) range from 0 to 76, with higher scores indicating fewer symptoms. Only time points for which data were available for five or more patients are shown. The number at risk shows the number of randomly assigned patients who were in the trial at each respective time point. I bars indicate standard errors.