Renal cell carcinoma is the predominant histological type of kidney cancer with historically poor patient outcomes. Lenvatinib in combination with pembrolizumab is an approved first-line regimen for people with advanced renal cell carcinoma that showed clinically meaningful improvements in efficacy over sunitinib in the CLEAR trial; however, reduced patient exposure to treatment (often stemming from adverse reactions) is a potential therapeutic barrier that must be addressed. Here, we present management strategies for adverse reactions associated with this treatment combination: fatigue, diarrhea, musculoskeletal pain, hypertension, stomatitis, decreased appetite, rash, nausea, and proteinuria. Dosing modification of lenvatinib and pembrolizumab should be made according to the prescribing information for each medication. Clinicians should consider that some adverse reactions, such as diarrhea, may be attributable to lenvatinib, or may be a symptom of immune-related adverse reactions to pembrolizumab (such as colitis). Adverse reactions can generally be managed by: (1) advising the patient on precautionary measures (eg, for stomatitis, practice dental hygiene, avoid irritating foods, and maintain adequate hydration), (2) monitoring for changes in symptoms from baseline (eg, changes in bowel movements, blood pressure or level of fatigue), (3) interrupting/dose reducing lenvatinib or interrupting pembrolizumab, if warranted, and advising the patient to manage their current symptoms via self-care (managing diarrhea with antidiarrheal agents and hydration), and (4) implementing medical interventions (eg, thyroid replacement or antihypertensive therapy) when needed. Through successful management of adverse reactions, oncology clinicians can improve the well-being of their patients and likely enhance adherence rates to treatment with lenvatinib and pembrolizumab.
Clinical genitourinary cancer. 2023 Dec 21 [Epub ahead of print]
Viktor Grünwald, James Larkin, Javier Puente, Jens Bedke, Camillo Porta
Interdisciplinary Genitourinary Oncology, Clinic for Urology, Clinic for Medical Oncology, University Hospital Essen, Hufelandstraße 55, 45147 Essen, Germany. Electronic address: ., The Royal Marsden Hospital, 203 Fulham Rd, SW3 6JJ, London, United Kingdom., Department of Medical Oncology, Hospital Clinico Universitario San Carlos, Calle del Prof Martín Lagos, S/N, 28040, Madrid, Spain., Department of Urology & Transplantation Surgery, Klinikum Stuttgart Kriegsbergstraße., 60 70174 Stuttgart Germany., Interdisciplinary Department of Medicine, University of Bari 'A Moro', Piazza Giulio Cesare 11 70124, Bari, Italy.