Progress in the treatment of kidney cancer has been nothing short of amazing in the past few years. Many new drugs have been introduced and FDA approved for first line therapy. This significantly expanded our armamentarium against this previously difficult to treat cancer. At the same time, rapid introduction of new agents has led to the situation in which there is there little evidence on how to select which one should be used first. The only the two drugs for which some evidence exists are Votrient(pazopanib) and Sutent(sunitinib). The first attempt to compare them was a patient preference study called PISCES, which showed 70% of patients preferred pazopanib and 22% preferred sunitinib.
The two drugs were directly compared in the COMPARZ trial. In the study, a total of 1,110 patients were treated with pazopanib or sunitinib . Treatment continued until disease progression, unacceptable toxicity, voluntary withdrawal, or death due to any cause. It showed that pazopanib had similar efficacy (i.e non-inferiority) compared to sunitinib in first-line treatment of metastatic renal cell carcinoma.
The most common adverse events (occurring in 30% or more of patients) that were more common with sunitinib were: fatigue (63% vs. 55%) hand-foot syndrome (50% vs. 29%); taste alteration (36% vs. 26%); and thrombocytopenia (34% vs. 10%). Side effects that were more common with pazopanib were ALT increase (31% vs. 18%) and hair whitening (30% vs. 10%). Additionally, 11 of the 14 quality-of-life measures were in favor of pazopanib over sunitinib, he reported. These included measures of fatigue, kidney symptoms, and mouth and throat soreness. A total of 42 percent of patients in the pazopanib arm and 41 percent in the sunitinib arm had serious adverse events. Strangely, despite patients’ preference for pazopanib, discontinuation rate of sunitinib was less.
Many experts are inclined to use Votrient first, because the patients prefer it and seem to tolerate it better, leading to fewer discontinuations in their experience. Others are not yet convinced. In any case, the results that these two drugs produce are certainly similar enough so that patient preference should play a major role in therapy selection.
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