How Kidney Cancer Is Treated

Treatment options for kidney cancer will depend on the stage of the disease and other factors. Most people, even those with advanced stages of the disease, will have some form of surgery. Additional treatments may include targeted therapies and immunotherapy. Chemotherapy and radiation are not commonly used.

Types of Treatment

Since both targeted therapy drugs and immunotherapy are relatively recent additions to the arsenal for cancer treatment, the therapy for people with kidney cancer has changed significantly in only the past few years.

Treatment options for kidney cancer are easier to understand if they are broken down into two categories:

  • Local treatments treat cancer where it originates and include surgery, cryosurgery, radiofrequency ablation, arterial embolization, and radiation therapy.
  • Systemic treatments address kidney cancer cells wherever they may be in the body (systemically) and include targeted therapy, immunotherapy, chemotherapy, and other treatments in clinical trials.

Many people diagnosed with kidney cancer will have a combination of these treatments. Again, it's important to note that treatment options have changed radically in just the past few years. In other words, if you talk to someone who was treated just three years ago, options may be very different today.

Surgery

Some type of surgery is performed for most people with kidney cancer. People with early-stage kidney cancer are the best candidates for surgery, but kidney cancer is one of the few solid tumors in which surgery may be beneficial even with advanced metastatic disease (stage 4).

Surgery Types

If a person has two functioning kidneys, removal of the entire kidney may easily be done, as only one kidney is needed for proper function. Some people, however, may have only one functioning kidney, or have a variant such as a horseshoe kidney, and this may influence the choice of procedure. Overall, the options for surgery can vary depending on the stage of kidney cancer and include:

  • Partial nephrectomy: In this procedure, the cancer plus some surrounding tissue is removed. With early-stage cancers (stage I) this can sometimes be curative.
  • Simple nephrectomy: A simple nephrectomy involves the removal of the whole kidney. A simple nephrectomy is often done for stage I kidney cancer (but a radical procedure may be done as well).
  • Radical nephrectomy: In addition to removing a whole kidney, a radical nephrectomy includes the removal of the adrenal glands, nearby lymph nodes, and some surrounding tissues (perirenal fat and Gerota fascia). A radical nephrectomy is often the recommended treatment for stage II and stage III kidney cancer and can be curative. (In very advanced cancers, the renal vein and part of the inferior vena cava may be removed as well).

As noted earlier, surgery is often done even for people with stage IV kidney cancer. If no distant spread is present (no distant metastases), a radical nephrectomy may be considered. For those who have distant metastases, a nephrectomy may be done as a palliative treatment (to improve symptoms or extend life) but not as a curative treatment.

Instead of a nephrectomy, radiation or embolization (see below) may be done to reduce the size of the original tumor. Further treatment options are discussed below.

Surgical Approaches

Just as there are different types of surgery that may be done, there are different approaches as well. These include:

  • Open nephrectomy: This is a traditional surgery in which a long incision is made to gain access and remove the kidney.
  • Laparoscopic nephrectomy: In a laparoscopic procedure, several small incisions are made in the abdominal wall. Special instruments are then inserted through these incisions through which the kidney (and any surrounding tissues) are removed.
  • Robotic surgery: Robotic surgery is similar to a laparoscopic procedure, but the actual surgery is performed with a robotic system.

When choosing a surgeon, it's very important to ask about experience, especially with the newer less invasive procedures. It's entirely appropriate to ask a potential surgeon how many of the procedures he or she has performed. In general, surgeons at cancer centers that perform greater volumes of these surgeries tend to have better outcomes.

Before having surgery, many advocates recommend getting a second opinion at a National Cancer Institute-designated cancer center. These larger cancer centers often have surgeons who specialize in these surgeries.

Side Effects

The common side effects of surgery include bleeding, infection, anesthesia risks, and the risk of blood clots following surgery. If a person has one normal kidney, kidney function is usually retained (you only need one kidney). If the other kidney is diseased, or if only one kidney is present and removed, dialysis (or a kidney transplant) will be needed.

Alternative Local Therapies

While surgery is the treatment of choice for most kidney cancers, this can be difficult in very elderly people or those with multiple serious medical conditions. For those who would not tolerate surgery, treatments such as cryosurgery (freezing the tumors) or radiofrequency ablation (burning the tumors) may be options.

Tumor Embolization

An arterial embolization is another local therapy that may be done to shrink a kidney tumor. In this procedure, the artery traveling to the kidney is threaded (like placing an IV but deep in the body) and a substance is injected that blocks the blood flow to the kidney. The tissue that is fed by the artery is therefore cut off from the blood flow and dies.

Adjuvant Therapy

Even if a kidney cancer is completely removed with surgery, there is a chance that it will recur. The treatments below may be used for kidney cancer that has spread (as a treatment for metastatic cancer), but may also be given after successful surgery to treat any remaining cancer cells that are too small to be seen on imaging tests.

Targeted Therapy

Targeted therapies are drugs that "target" specific pathways in the growth and spread of cancer cells. Since it is only recently that we have learned about the genetic changes and molecular pathways involved in the growth of cancer, the majority of these drugs were not available until very recently. Unlike chemotherapy (a treatment that attacks any rapidly dividing cells), targeted therapies interfere primarily with cancer cells alone, and as such, often have fewer side effects.

Targeted therapies do not kill cancer cells directly, but function by simplistically "starving" tumor cells. As such, they do not usually cure a cancer, but some of these drugs may allow a tumor to be controlled or kept in check for a significant period of time (just like a chronic disease).

Different targeted therapy drugs work in different ways.

  • Angiogenesis inhibitors: These drugs work to prevent the growth of blood vessels (angiogenesis) that are needed for tumors to grow. An example is Avastin bevacizumab.
  • Kinase inhibitors: These drugs work to block the growth of cancer cells. Examples include the mTOR inhibitors Afinitor (everolimus) and Torisel (emsirolimus), as well as Nexavar (sorafenib), Sutent (sunitinib), Votrient (pazopanib), Inlyta (axitinib), and Cabometyx (cabozantinib). A different type of kinase inhibitor, Tarceva (erlotinib) may be used for clear cell type kidney cancer.

Side Effects

Kinase inhibitors vary in side effects, but many of them are mild. Angiogenesis inhibitors can cause high blood pressure, bleeding, and occasionally bowel perforation.

Immunotherapy

Immunotherapy, also known as biologic therapy, is a group of treatments that work by stimulating our own immune systems to fight cancer. Immunotherapy actually includes a wide variety of treatment types. The most common drugs used with kidney cancer include:

  • Checkpoint inhibitors: Checkpoint inhibitors such as Opdivo (nivolumab), Yervoy (ipilimumab), and Tecentriq (atezolizumab) work by essentially taking the brakes off the immune system so that it can fight cancer.
  • Cytokines: Cytokines such as interferon and interleukin-2 are non-specific immunotherapy drugs that stimulate the immune system to fight off any foreign invader, including cancer cells.

When effective, immunotherapy can sometimes have a dramatic effect even with very advanced cancers.

Side Effects

Side effects of immunotherapy drugs may vary, but often include a fever, skin rash, cough, high potassium and low sodium levels, and conditions that end with "itis," such as pneumonitis (inflammation of the lungs) and hepatitis (inflammation of the liver).

Chemotherapy

Chemotherapy uses drugs that interfere with the division of cells to kill cancer cells. Since chemotherapy drugs kill off all rapidly dividing cells (not just cancer cells), it often gives rise to side effects related to normal cells that divide rapidly, such as hair follicles (hair loss), bone marrow cells (a low white blood cell count, red blood cell count, and platelets), and digestive tract cells (causing nausea and vomiting).

There are a number of different drugs that may be used, but these are used less commonly with kidney cancer than with some other cancers, as they have often have little effect.

Radiation Therapy

Radiation therapy uses high energy x-rays to damage tissues. It may be given externally (external beam radiation) or internally via the placement of radioactive seeds (brachytherapy). Radiation may be used as an adjuvant treatment after surgery to address any cancer cells that may be left over, or as a palliative treatment (treatments used to reduce the symptoms of advanced cancer but not cure cancer).

A specialized form of radiation therapy called stereotactic body radiotherapy (SBRT) has been increasingly used in recent years to treat isolated (only a few) metastases from kidney cancer to the brain or spinal cord. In this procedure, a high dose of radiation is given to a localized area of tissue (such as a spot of kidney cancer that has spread to the brain) in an attempt to cure the metastasis. It's too soon to really know how this may affect outcomes, but in properly selected people it may have the ability to extend life.

This approach of treating only a single or a few areas of spread (called "oligometastases" in medical lingo) is relatively new, but has been found to improve outcomes for people with some types of cancer which had spread and was previously untreatable.

Clinical Trials

There are currently many clinical trials in progress looking at better ways to treat cancer. These research studies are looking at combinations of the above treatments, as well as newer treatments that have not yet been approved.

According to the National Cancer Institute, all people newly diagnosed with kidney cancer can be considered candidates for clinical trials when possible. Many people are frightened about the option of clinical trials, but it's helpful to keep in mind that all treatments currently used for kidney cancer were once studied in clinical trials. In the case of the most commonly used medications for metastatic kidney cancer, many of these were only available in clinical trials even a year or so ago.

As an example, a 2018 review and meta-analysis concluded that, for first-line treatment of metastatic kidney cancer, Cabometyx and Opdivo plus Yervoy are likely to be the best choices. Cabometyx was only approved in the United States for first-line treatment of kidney cancer in December of 2017 (it was approved for kidney cancer that failed other treatments in 2016), and Opdivo and Yervoy were only approved in 2016.

Most of the medical research studies in progress for kidney cancer are looking at drugs that specifically target kidney cancer cells, and therefore have a much higher probability of being effective than treatments studied in the past.

As a final note with treatments and clinical trials, it's very helpful if you can be your own advocate in your cancer care or have someone who can advocate for you. With treatments changing this rapidly among many cancer types, it's hard for anyone to keep up with the latest research findings. But nobody is as motivated to learn about the best treatments (or those with the least side effects) as someone who is living with the disease or their loved ones.

Complementary Medicine (CAM)

There are no alternative therapies that have been found to effectively treat kidney cancer, but some of these therapies may help ease the symptoms of cancer and cancer treatments. Integrative cancer therapies such as meditation, massage, and acupuncture are now available at many cancer centers.

As a note, it's important to talk to your doctor about any dietary supplements or vitamin or mineral supplements you are considering, as some of these could potentially interfere with cancer treatments. This is easier to understand if you think about how these treatments work. Treatments such as chemotherapy and radiation therapy are designed to damage cancer cells. Therefore, preparations such as antioxidant supplements may not be wise, as they could potentially "protect" cancer cells from these treatments.

Home Remedies and Lifestyle

While lifestyle practices are seldom discussed when it comes to "treatment options," they are no less important. Having a strong social network can ease the anxiety and distress associated with a cancer diagnosis, and with some cancers has even been linked with outcomes. It can also be more isolating to be diagnosed with kidney cancer than some other cancers such as breast cancer or prostate cancer. You may not know anyone who has the disease, and there may not be a support group in your community.

Fortunately, the age of the internet greatly expands access for people with less common cancers. The organization Inspire, in conjunction with the Kidney Cancer Association, has an active kidney cancer community. There are many other kidney cancer communities online as well. Facebook groups exclusively for those living with kidney cancer are available, and those who are active on Twitter can find others using the hashtag #KidneyCancer.

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