Axitinib Given on an Individualized Schedule for Metastatic Renal Cell Cancer

Axitinib is a drug which is approved by the FDA for patients with advanced kidney cancer who have already received some treatment. It works by reducing blood flow to a tumor. Axitinib is normally give at 5mg twice per day and sometimes this dose is increased if patients tolerate it. The purpose of this study is to figure out a different way to decide which dose of axitinib each patient should receive based on the side effects they experience.

Primary objective To determine whether axitinib given on an individualized dose/schedule for metastatic renal cell carcinoma following immunotherapy with PD-1 and PD-L1 Inhibitors leads to improved progression-free survival (PFS).

Secondary objectives:

1. To characterize the objective response rates in patients given axitinib on an individualized dose/schedule.
2. To evaluate the tolerability and safety of an alternative method of axitinib titration.
3. To characterize the anti-tumor effect, as measured by change in tumor burden per RECIST 1.1, of axitinib titration performed after initial RECIST PD on axitinib.

Eligibility Criteria:
Inclusion Criteria:

* Histologically confirmed, locally recurrent or metastatic clear cell renal cell carcinoma
* Has received one prior systemic therapy regimen for Metastatic Renal Cell Carcinoma (mRCC) directed against PD-1 and/or PD-L1 which must have been the most recent regimen

  * Prior high-dose interleukin-2 therapy is permitted in addition to anti-PD(L)1 therapy, but is not required
  * Prior bevacizumab or Vascular Endothelial Growth Factor (VEGF) Tyrosine Kinas Inhibitor (TKI) is permitted either in combination with anti-PD(L)1 therapy OR as monotherapy when given PRIOR to anti-PD(L)1 therapy
  * Prior treatment with combined ipilimumab and nivolumab is permitted
  * Prior axitinib in any setting is not permitted
  * A minimum of two weeks since last dose of most recent renal cell cancer therapy assuming resolution of clinically significant treatment-related toxicities to grade 1, baseline, or controlled with supportive medications
* Evidence of measurable disease per RECIST 1.1.
* Karnofsky performance status ≥ 70 %.
* Adequate organ function as defined by:

  * Absolute neutrophil count (ANC) ≥1,000/μL
  * Platelets ≥100,000/μL
  * Hemoglobin ≥9.0 g/dL
  * Serum calcium ≤12.0 mg/dL
  * Serum creatinine ≤2.0 x Upper Limit of Normal (ULN)
  * Total serum bilirubin ≤1.5 x ULN
  * SGOT≤2.5 x ULN and Serum Glutamic Pyruvic Transaminase (SGPT) ≤2.5x ULN
* Signed informed consent and willingness/ability to comply with scheduled visits, treatment plans, laboratory tests, and other study procedures

Exclusion Criteria:

* Non clear cell Renal Cell Carcinoma (RCC)
* Major surgery within 4 weeks of starting the study treatment.
* Radiation therapy within 2 weeks of starting the study treatment. Prior palliative radiotherapy to metastatic lesion(s) is permitted, provided there is at least one measurable lesion that has not been irradiated.
* NCI CTCAE Version 4.03 grade 3 hemorrhage within 4 weeks of starting the study treatment.
* Any of the following within the 6 months prior to study drug administration: myocardial infarction, severe/unstable angina, coronary/peripheral artery bypass graft, symptomatic congestive heart failure, cerebrovascular accident or transient ischemic attack.
* Ongoing cardiac dysrhythmias of NCI CTCAE Version 4.03 grade ≥2. Controlled atrial fibrillation is permitted.
* Uncontrolled hypertension (\>160/100 mm Hg despite optimal medical therapy)
* Concurrent treatment on another clinical trial. Supportive care trials or non-treatment trials, e.g. QOL, and imaging trials, are allowed.
* Pregnancy or breastfeeding. Female subjects must be surgically sterile or be postmenopausal, or must agree to use effective contraception during the period of therapy. All female subjects with reproductive potential must have a negative pregnancy test (serum) prior to enrollment. Male subjects must be surgically sterile or must agree to use effective contraception during the period of therapy. The definition of effective contraception will be based on the judgment of the principal investigator or a designated associate
* Other severe acute or chronic medical or psychiatric condition or laboratory abnormality that may increase the risk associated with study participation or study drug administration, or may interfere with the interpretation of study results, and in the judgment of the investigator would make the subject inappropriate for entry into this study.
* Uncontrolled Central Nervous System (CNS) metastases. Patients are considered to have controlled CNS metastases (and thus eligible) if they have completed local therapy (XRT and/or surgery) and are off steroids with clinical and radiographic stability 3 months from the end of CNS-directed therapy.