• Brian I Rini, Bernard Escudier, Piotr Tomczak, Andrey Kaprin, Cezary Szczylik, Thomas E Hutson, M Dror Michaelson, Vera A Gorbunova, Martin E Gore, Igor G Rusakov, Sylvie Negrier, Yen-Chuan Ou, Daniel Castellano, Ho Yeong Lim, Hirotsugu Uemura, Jamal Tarazi, David Cella, Connie Chen, Brad Rosbrook, Sinil Kim, and Robert J Motzer.
• Cleveland Clinic Taussig Cancer Institute, Main Campus, Euclid Avenue, Cleveland, OH 44195, USA. rinib2@ccf.org
• Lancet. 2011 Dec 3; 378 (9807): 1931-9.

BackgroundThe treatment of advanced renal cell carcinoma has been revolutionised by targeted therapy with drugs that block angiogenesis. So far, no phase 3 randomised trials comparing the effectiveness of one targeted agent against another have been reported. We did a randomised phase 3 study comparing axitinib, a potent and selective second-generation inhibitor of vascular endothelial growth factor (VEGF) receptors, with sorafenib, an approved VEGF receptor inhibitor, as second-line therapy in patients with metastatic renal cell cancer.MethodsWe included patients coming from 175 sites (hospitals and outpatient clinics) in 22 countries aged 18 years or older with confirmed renal clear-cell carcinoma who progressed despite first-line therapy containing sunitinib, bevacizumab plus interferon-alfa, temsirolimus, or cytokines. Patients were stratified according to Eastern Cooperative Oncology Group performance status and type of previous treatment and then randomly assigned (1:1) to either axitinib (5 mg twice daily) or sorafenib (400 mg twice daily). Axitinib dose increases to 7 mg and then to 10 mg, twice daily, were allowed for those patients without hypertension or adverse reactions above grade 2. Participants were not masked to study treatment. The primary endpoint was progression-free survival (PFS) and was assessed by a masked, independent radiology review and analysed by intention to treat. This trial was registered on ClinicalTrials.gov, number NCT00678392.FindingsA total of 723 patients were enrolled and randomly assigned to receive axitinib (n=361) or sorafenib (n=362). The median PFS was 6·7 months with axitinib compared to 4·7 months with sorafenib (hazard ratio 0·665; 95% CI 0·544-0·812; one-sided p<0·0001). Treatment was discontinued because of toxic effects in 14 (4%) of 359 patients treated with axitinib and 29 (8%) of 355 patients treated with sorafenib. The most common adverse events were diarrhoea, hypertension, and fatigue in the axitinib arm, and diarrhoea, palmar-plantar erythrodysaesthesia, and alopecia in the sorafenib arm.InterpretationAxitinib resulted in significantly longer PFS compared with sorafenib. Axitinib is a treatment option for second-line therapy of advanced renal cell carcinoma.FundingPfizer Inc.Copyright © 2011 Elsevier Ltd. All rights reserved.

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