Kidney cancer: Treatment options

Kidney cancer: Treatment options

ON THIS PAGE: you will get information about the different ways that doctors use to treat people with this type of cancer. To see other pages, use the menu.

This section describes the treatments that are the standard of care for this type of cancer. "Standard of care" means the best known treatments. When making decisions related to the treatment plan, patients are also advised to consider the option of participating in clinical trials. A clinical trial is a research study that tests a new approach to treatment. Doctors want to know if it is safe, effective and possibly better than standard treatment. Clinical trials can test a new drug, a new combination of standard treatments or new doses of standard drugs or other treatments. Your doctor can help you consider all of your treatment options. For more information about clinical trials, see the sections About Clinical Trials and Latest Research.
General description of the treatment

In cancer care, different types of doctors often work together to create a comprehensive treatment plan for the patient that combines different types of treatments. This is called a multidisciplinary team (in English). In kidney cancer, the health care team is usually run by a urologist, who is a doctor who specializes in the genitourinary tract, which includes the kidneys, bladder, genitals, prostate and testes, or a urologist oncologist, who It specializes in treating cancers of the urinary tract. Cancer care teams also include a variety of other health care professionals, including medical assistants, oncology nurses, social workers, pharmacists, counselors, nutritionists, and others.

The recommendations and treatment options depend on several factors, including the type, cell type and stage of the cancer, possible side effects, as well as the patient's preferences and general health. Your plan of care may also include treatment for symptoms and side effects, an important part of cancer care. Take time to get information about all your treatment options and be sure to ask questions about things that are not clear. Also, talk to your doctor about the goals of each treatment and what you can expect while receiving the treatment. Learn more about making treatment decisions (in English).

Kidney cancer is most often treated with surgery, targeted therapy, immunotherapy, or a combination of these treatments. Radiation therapy and chemotherapy are used occasionally. Patients with kidney cancer that has spread (metastatic cancer, see below) often receive multiple lines of therapy, which are treatments administered one after the other. Next, the treatment options are described.
Active surveillance

Sometimes, the doctor may recommend controlling the tumor closely by performing diagnostic tests and appointments to the clinic on a regular basis. This is called active surveillance. Active surveillance is effective in older adults and patients with a small renal tumor and other serious medical conditions, such as heart disease, chronic kidney disease, or severe lung disease. Active surveillance can also be used for some patients with kidney cancer, even if it has spread to other parts of the body (metastasized).

Active surveillance is not the same as watchful waiting. Watchful waiting involves periodic appointments to check for symptoms, but patients are not regularly screened for diagnosis, such as a biopsy or imaging tests. The doctor simply observes the symptoms. If symptoms suggest that action should be taken, then a new treatment plan is considered.
Surgery

Surgery is the removal of the tumor and part of the surrounding healthy tissue during an operation. If the cancer has not spread outside the kidneys, surgery to remove the tumor, part of the kidney or entire kidney, and possibly tissue and nearby lymph nodes may be the only treatment needed.

The types of surgery used for kidney cancer include the following procedures:

    Radical nephrectomy. Surgery to remove the tumor, the entire kidney, and surrounding tissues is called radical nephrectomy. If the nearby tissue and the surrounding lymph nodes are also





affected by the disease, a radical nephrectomy and a dissection of the lymph nodes are performed. During lymph node dissection, the lymph nodes affected by the cancer are removed. If the cancer has spread to the adrenal gland or nearby blood vessels, the surgeon may remove this gland during a procedure called adrenalectomy and parts of the blood vessels. Radical nephrectomy is usually recommended to treat a large tumor when there is little remaining healthy tissue. Sometimes, the kidney tumor will grow directly into the renal vein and enter the renal cava toward the heart. If this happens, complicated cardiovascular surgical techniques should be used to safely remove all the disease.

    Partial nephrectomy. A partial nephrectomy is the surgical removal of a tumor. This type of surgery preserves kidney function and decreases the risk of developing chronic kidney disease after surgery. Research has shown that, in cases where it is technically possible, partial nephrectomy is equally effective for T1 tumors. The newer approaches that use a smaller surgical incision, or cut, are associated with fewer side effects and faster recovery.

    Laparoscopic and robotic surgery (minimally invasive surgery). During laparoscopic surgery, the surgeon makes several small incisions instead of a single larger incision in the abdomen, such as is used during a traditional surgical procedure. Then, the surgeon inserts the telescopic equipment into these small minimally invasive incisions to remove the entire kidney or perform a partial nephrectomy. Sometimes the surgeon can use robotic instruments to perform the operation. This surgery may take more time, but it may be less painful. Laparoscopic and robotic approaches require specialized training. It is important to discuss the benefits and potential risks of this type of surgery with your surgical team and be sure that the team has experience with the procedure.

Sometimes surgery is not recommended because of the characteristics of the tumor or the general health of the patient. Instead, the following procedures can be recommended:

    Radiofrequency ablation. Radiofrequency ablation (RFA) involves using a needle inserted into the tumor to destroy the cancer with an electrical current. The procedure is in charge of a radiologist or urologist. The patient receives a sedative and local anesthesia to numb the area. In the past, RFA had only been used in patients who were very ill to undergo surgery. Currently, most of these patients are controlled by active surveillance (see above).

    Cryoablation Cryoablation (also called cryotherapy or cryosurgery) involves freezing cancer cells with a metal probe that is inserted through a small incision. The metal probe is placed in the cancerous tissue. CT and ultrasound are used to guide the probe. This procedure requires general anesthesia for several hours. Some surgeons combine this technique with laparoscopy to treat the tumor, but there is very little evidence of long-term research to know its effectiveness. Talk to your doctor before surgery about what side effects are likely by virtue of the type of surgery that will be performed and what can be done to reduce or manage these side effects. Learn more about the basics of cancer surgery.

Targeted therapy

Targeted therapy is a treatment that targets tissue conditions, proteins or cancer-specific genes that contribute to the growth and survival of cancer. This type of treatment blocks the growth and spread of cancer cells and, at the same time, limits damage to healthy cells. These medications are becoming more important in the treatment of kidney cancer.

Recent studies show that not all tumors have the same targets. Many research studies are currently under way to obtain more information about specific molecular targets and new treatments aimed at them. Learn more about the basics of targeted treatments.

    Antiangiogenic therapy. This type of treatment focuses on stopping angiogenesis, which is the process of forming new blood vessels. Since a tumor needs nutrients transported by blood vessels to grow and spread, the goal of antiangiogenic therapies is to "starve" the tumor. It was shown that an antiangiogenic drug, called bevacizumab (Avastin), slows tumor growth in




people with metastatic renal carcinoma. Bevacizumab combined with interferon (see Immunotherapy below) slows the growth and spread of the tumor.

    Tyrosine kinase inhibitors (ITC). Clear cell kidney cancer has a mutation of the VHL gene that causes cancer to produce an excessive amount of a certain protein, known as vascular endothelial growth factor (VEGF). VEGF controls the formation of new blood vessels. Drugs called ITC help block VEGF and other chemical signals that promote the development of new blood vessels. TCIs such as cabozantinib (Cabometyx), pazopanib (Votrient), sorafenib (Nexavar) and sunitinib (Sutent) can be used in the treatment of clear cell kidney cancer. Axitinib (Inlyta), another ITC, has been approved for the treatment of late renal cell carcinoma. Side effects of ITC can include diarrhea, high blood pressure and pain and tenderness in the hands and feet.

    MTOR inhibitors. Everolimus (Afinitor) and temsirolimus (Torisel) are drugs that target a protein called mTOR that helps the growth of kidney cancer cells. Studies show that these drugs slow the growth of kidney cancer.

Talk with your doctor about the possible side effects of each specific medication and how they can be managed. The medicines used to treat cancer are constantly evaluated. Often, talking to your doctor is the best way to get information about the medications you were prescribed, their purpose and potential side effects or interactions with other medications. Get more information about your prescription medications using searchable drug databases (in English).
Immunotherapy

Immunotherapy, also called biological therapy, is designed to strengthen the body's natural defenses in order to fight cancer. Use materials produced by the body or manufactured in a laboratory to improve, direct or restore the function of the immune system.

Interleukin 2 (IL-2, Proleukin) is a type of immunotherapy that has been used to treat late kidney cancer. It is a cell hormone called cytokine that is produced by white blood cells. It is important in the function of the immune system, which includes the destruction of tumor cells.

A high dose of IL-2 can cause severe side effects, such as low blood pressure, excess fluid in the lungs, kidney damage, heart attack, bleeding, chills, and fever. Patients may need to stay in the hospital for up to 10 days during treatment. However, some symptoms may be reversible. Only centers with experience in treatment with high doses of IL-2 for kidney cancer should recommend the use of IL-2. A high dose of IL-2 can cure a small percentage of patients with metastatic kidney cancer. Some centers use low doses of IL-2 because they have fewer side effects, although they do not have the same effectiveness.

Alpha interferon is another type of immunotherapy agent used in the treatment of kidney cancer that has spread. Interferon appears to modify proteins on the surface of cancer cells and slow their growth. Although it has not been proven to be as beneficial as IL-2, it has been proven that alpha interferon lengthens life compared to an older treatment called megestrol acetate (Megace).

Researchers have tested various combinations of IL-2 and alpha interferon for patients with advanced kidney cancer. These treatments have also been combined with chemotherapy (see below). It has not been shown in research studies that these combinations are better than the individual administration of IL-2 or interferon.

Researchers are working to learn more about how IL-2 and interferon destroy kidney cancer cells and which patients can benefit most from these treatments.

Recently, a new form of immunotherapy called checkpoint inhibitors (see below) has been evaluated in kidney cancer. A drug called nivolumab (Opdivo) administered through a vein every two weeks was shown to help certain patients who had




received treatment before to live longer than patients who had received everolimus. There is a lot of research being done on these types of drugs to treat kidney cancer (see the Latest Research section).

Talk with your doctor about possible side effects of the type of immunotherapy recommended, as well as how they will be controlled. Learn more about the basics of immunotherapy.
Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by inhibiting their ability to grow and divide. Chemotherapy is administered by a clinical oncologist, a doctor who specializes in cancer treatment with medications.

Systemic chemotherapy enters the bloodstream to reach cancer cells throughout the body. Some common methods of chemotherapy include an intravenous (IV) tube that is placed in a vein with a needle, or a pill or capsule that is swallowed (orally).

A chemotherapy regimen (program) usually consists of a specific number of cycles that are administered in a given period. A patient can receive 1 drug at a time or combinations of different drugs at the same time.

While chemotherapy is useful for treating most types of cancer, kidney cancer is often resistant to chemotherapy. In any case, researchers continue to study new drugs and new combinations of drugs. In some patients, the combination of gemcitabine (Gemzar) with capecitabine (Xeloda) or fluorouracil (5-FU, Adrucil) temporarily reduces the size of the tumor.

It is important to remember that transitional cell carcinoma, also called urothelial carcinoma, and Wilms tumor (in English) are much more likely to be successfully treated with chemotherapy.

The side effects of chemotherapy depend on the patient and the dose used, but may include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite and diarrhea. These side effects usually disappear once the treatment is finished.

Learn more about the basics of chemotherapy and how to prepare for treatment. The medicines used to treat cancer are constantly evaluated. Often, talking to your doctor is the best way to get information about the medications you were prescribed, their purpose and potential side effects or interactions with other medications. Get more information about your prescription medications using searchable drug databases (in English).
Radiotherapy

Radiation therapy is the use of X-rays or other particles with high potency to destroy cancer cells. The doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.

Radiation therapy is not effective as a primary treatment for kidney cancer. It is rarely used alone to treat kidney cancer because of the damage it causes to the healthy kidney. Radiation therapy is used only if a patient can not undergo surgery and, even under those circumstances, is usually used only in areas where the cancer has spread, not in the primary tumor of the kidney. Most of the time, radiation therapy is used when the cancer has spread, to help relieve symptoms, such as bone pain or brain swelling.

The most common type of radiation treatment is called external beam radiation therapy, which consists of radiation that is applied from a machine external to the body. When radiation treatment is given using implants, the treatment is called internal radiotherapy or brachytherapy. For kidney cancer, internal radiation therapy is administered with a hollow needle through which radioactive seeds are inserted directly into the tumor. Another type of radiation therapy is stereotactic radiosurgery, which is designed to direct radiation therapy to a specific area without damaging nearby tissue.

A regimen (program) of radiotherapy, usually, consists of a specific amount of treatments that are administered in a certain period.



tion therapy may include fatigue, mild skin reactions, upset stomach, and loose stools. Internal radiation therapy can cause bleeding, infection, and risk of injury to nearby tissue. Most side effects disappear shortly after the end of treatment.
Learn more about the basics of radiation therapy.
How to get care for symptoms and side effects

Often, cancer and its treatment cause side effects. In addition to treatment to delay, stop or eliminate cancer, an important aspect of cancer care is to alleviate the symptoms and side effects of the person. This approach is called palliative care or supportive medical care and includes providing support to the patient with physical, emotional and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving the quality of life and providing support to patients and their families. Anyone, regardless of age or type and stage of cancer, can receive palliative care. Palliative care works best when it starts as soon as it is needed in the cancer treatment process.

Often, people receive cancer treatment and treatment to relieve side effects at the same time. In fact, patients who receive both treatments often have less severe symptoms, better quality of life and report that they are more satisfied with the treatment.

Palliative treatments vary widely and often include medications, nutritional changes, relaxation techniques, emotional support and other therapies. You can also receive palliative treatments similar to those used to eliminate cancer, such as chemotherapy, surgery or radiation therapy. Talk to your doctor about the goals of each treatment in your treatment plan.

Talk with your health care team about possible side effects of your specific treatment plan and hospice options before starting treatment. Also, during and after treatment, be sure to tell your doctor or another member of the health care team if you experience a problem, so that it can be addressed as soon as possible. Get more information about palliative care.
Metastatic kidney cancer

If the cancer spreads to another part of the body from where it started, doctors call it metastatic cancer. This is a systemic disease that requires systemic therapy, such as targeted therapy or immunotherapy. Often, doctors may ask a surgeon to remove the kidney with the tumor in a surgical procedure called cytoreductive nephrectomy. This prevents pain and bleeding during systemic treatment and is associated with a better prognosis.

The most common place where kidney cancer spreads is in the lungs, but it can also spread to the lymph nodes, bones, liver, brain, skin and other areas of the body. In the case of a kidney cancer that has spread to a specific part of the body, such as the lungs, surgery may be able to completely eliminate the cancer. If the cancer has spread to many areas beyond the kidneys, treatment is more difficult.

If the cancer has spread, it is a good idea to talk to doctors who have experience in treating it. Doctors may have different opinions about the best standard treatment plan. Clinical trials may also be an option. Get more information about the search for a second opinion (in English) before starting the treatment, in order to be calm with the chosen treatment plan. If the cancer has spread to other parts of the body, it is called metastatic cancer.

Currently, the most effective treatment for metastatic kidney cancer is targeted therapy, which delays or prevents tumor growth and blood vessel formation. It was shown that these drugs lengthen life compared to standard treatment. Palliative care is also important to help relieve symptoms and side effects.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to cope with. Patients and their families are advised to talk about how they feel about doctors, nurses, social workers or other members of the health care team. Talking with other patients can also be helpful, including going to a support group.
Remission and the likelihood of recurrence




A remission occurs when the cancer can not be detected in the body and there are no symptoms. This can also be called "no evidence of disease" (NED).

A referral can be temporary or permanent. This uncertainty makes many people worry that the cancer will return. Although many referrals are permanent, it is important to talk to your doctor about the possibility of the cancer coming back. Understanding the risk of recurrence and treatment options can help you feel more prepared if, indeed, the cancer comes back. Learn more about coping with the fear of recurrence (in English).

If the cancer comes back after the original treatment, it is called recurrent cancer. It can reappear in the same place (which is called local recurrence), in the vicinity (regional recurrence) or elsewhere (recurrence at a distance). If you have already had a partial nephrectomy, it is possible that a new tumor forms in that kidney. The recurrent tumor can be excised with another partial nephrectomy or with a radical nephrectomy.

When the disease comes back, it will start a test cycle again to get as much information as possible about the recurrence. After the tests are done, you and your doctor will discuss your treatment options. Often, the treatment plan will include the treatments described above, such as surgery, targeted therapy, immunotherapy, radiation therapy, and chemotherapy, but they can be used with a different combination or administered at a different rate. Your doctor may also suggest clinical trials that are studying new methods to treat this type of recurrent cancer. Whichever treatment plan you choose, palliative care will be important to alleviate symptoms and side effects.

Often, people with recurrent cancer experience emotions such as disbelief or fear. Patients are advised to talk with the health care team about these feelings and to consult about support services that help them cope. Get more information on how to cope with cancer recurrence (in English).
If the treatment fails

Recovering from cancer is not always possible. If the cancer can not be cured or controlled, the disease can be called advanced or terminal.

This diagnosis is stressful and, for many people, talking about advanced cancer is difficult. However, it is important that you have open and honest conversations with your doctor and the health care team in order to express your feelings, preferences and concerns. The health care team aims to help, and many of its members have special skills, experience and knowledge to support patients and their families. Making sure a person is physically comfortable and does not feel pain is extremely important.

It is possible that patients with advanced cancer and with a life expectancy of less than 6 months want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people nearing the end of life. It is advised that you and your family think where you would be most comfortable: at home, in the hospital or in a hospice. Nursing care and special equipment can make staying at home a feasible alternative for many families. Get more information on advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Get more information about suffering and loss (in English).

The next section of this guide is About clinical trials. It offers more information about research studies that focus on finding better ways to care for people with cancer. Or, use the menu to choose another section, so continue reading this guide.