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  • Treatment for kidney cancer

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    Treatment for early kidney cancer

    Early kidney cancer (stages I and II) is localised. That means the cancer is found only in the kidney or has not spread very far. The main treatment is surgery to remove the tumour from the body. Less often, non-surgical treatments, such as radiofrequency ablation and stereotactic body radiation therapy, are used to try to kill the tumour. Sometimes the best approach for localised kidney cancer is not immediate treatment, but to watch the cancer carefully (active surveillance).

    Active surveillance

    When small tumours (less than 4 cm in diameter) are found in the kidney, they are less likely to be aggressive and might not grow during a person’s lifetime. In this case, your doctor might recommend active surveillance, also known as observation. This involves regular ultrasounds or CT scans. If these imaging tests suggest that the tumour has grown at any time, you will be offered treatment (usually surgery).

    Active surveillance might help to avoid the loss of kidney function and other side effects you may experience after surgery. It can also be a reasonable option if you are not well enough for an operation and the tumours are small.

    You might feel anxious about not treating a cancer in your body right away. However, active surveillance is a common approach for early kidney cancer and will only be recommended if the doctor thinks it is the best thing to do. If you are worried, discuss your concerns with your urologist, GP or a counsellor.

    Surgery

    Surgery is the main treatment for kidney cancer that has not spread outside the kidney. Depending on the type of kidney cancer, the grade and stage of the cancer, and your general health, you might have one of the following operations:

    Removing part of the kidney (partial nephrectomy) 

    This is the preferred option for small tumours that are confined to the kidney. It may also be used for people with pre-existing kidney disease, cancer in both kidneys or only one working kidney. Only the cancer and a small part of the kidney are removed, which means more of the kidney’s function is preserved. A partial nephrectomy is a more difficult operation than a radical nephrectomy, and whether it is possible depends on the position of the tumour.

    Removing the whole kidney (radical nephrectomy) 

    This is the most common operation for large tumours. The whole affected kidney, a small part of the ureter and the surrounding fatty tissue are removed. The adrenal gland and nearby lymph nodes might also be removed. Sometimes the kidney cancer may have spread into the renal vein and even into the vena cava, the main large vein that runs up the body next to the spine. Even if the cancer is in the vena cava, it is sometimes possible to remove all the cancer in one operation.

    If a whole kidney or part of a kidney is removed, the remaining kidney usually carries out the work of both kidneys. Your doctor will talk to you about any steps you need to take to protect the remaining kidney.

    How the surgery is done

    If you have surgery for kidney cancer, it will be carried out in hospital under a general anaesthetic.

    Your surgeon will talk to you about the risks of the procedure. Your surgeon will use one of the following methods to remove part or all of the kidney (partial or radical nephrectomy). Each method has advantages in particular situations.

    Open surgery – A long cut (incision) is made at the side of your abdomen where the affected kidney is located. In some cases, the incision is made in the front of the abdomen or in another area of the body where the cancer has spread. If you are having a radical nephrectomy, the surgeon will clamp off the major blood vessels and tubes in the affected kidney before removing it.

    Laparoscopic surgery – This is sometimes called keyhole or minimally invasive surgery. The surgeon will make several small cuts in the skin and insert a tiny instrument with a light and camera (laparoscope) into one of the cuts. The laparoscope takes pictures of your body and displays them on a TV screen. The surgeon inserts tools into the other cuts and performs the surgery using the images on the screen for guidance.

    Robot-assisted surgery – This is a type of laparoscopic surgery. A surgeon makes small cuts in the abdomen, and the camera and instruments are inserted through the cuts to perform the surgery. The surgeon has a 3D view that can be magnified up to 10–12 times and carries out the surgery using a machine to control the robotic arms.

    Making decisions about surgery

    Talk to your surgeon about the types of surgery available to you, and the pros and cons of each option. If your surgeon suggests robotassisted surgery, check what fees are involved – unless you are treated as a public patient in a hospital or treatment centre that offers this at no extra cost, it can be an expensive operation.

    Compared to open surgery, both standard laparoscopic surgery and robot-assisted surgery usually mean a shorter hospital stay, less pain and a faster recovery time. However, open surgery may be a better option in some situations.

    Other treatments

    Surgery is the most accepted treatment for early kidney cancer. However, if you are not well enough for surgery and the tumour is small, your doctor may recommend another type of treatment to destroy or control the cancer.

    Radiofrequency ablation (RFA) – Radiofrequency ablation uses high-energy radio waves to heat the tumour. The heat kills the cancer cells and forms internal scar tissue. For this procedure, the doctor inserts a fine needle into the tumour through the skin, using a CT scan as a guide. An electrical current is passed into the tumour from the needle. The treatment takes about 15 minutes and you can usually go home after a few hours. Side effects, including pain or fever, can be managed with medicines.

    Stereotactic body radiation therapy (SBRT) – Radiation therapy uses a controlled dose of radiation, such as x-ray beams, to kill or damage cancer cells. Standard radiation therapy is not effective in treating primary kidney cancer and is given primarily to control symptoms such as bleeding or pain. Some studies, however, show promising results for SBRT as a treatment for kidney cancer and your doctor may recommend it in particular situations. SBRT is a highly targeted form of radiation therapy that delivers tightly focused beams of high-dose radiation precisely onto the tumour from many different angles. SBRT is sometimes called stereotactic ablative body radiation therapy (SABR).

    Treatment for advanced kidney cancer

    When kidney cancer has spread outside the kidney to other parts of the body, the usual goal of treatment is to control the cancer, to slow down its spread and to manage any symptoms.

    A combination of different treatments may be recommended by your treatment team. The best combination of treatments depends on many factors, so the right approach for each person will vary:

    • Watching and waiting (active surveillance) may be an option for some people.
    • Systemic treatment with targeted therapy or immunotherapy drugs is the main medical treatment to help control advanced kidney cancer. Since the development of these more effective treatments, chemotherapy is rarely used.
    • Radiation therapy may be suitable for some people.
    • Surgery to remove the affected kidney might be recommended in certain circumstances, for example, if the cancer is causing symptoms.

    Active surveillance

    In some cases when kidney cancer has spread, the cancer grows so slowly that it won’t cause any problems for a very long time. Because of this, especially if the advanced kidney cancer has been discovered unexpectedly, your doctor may suggest observing the cancer at regular intervals, usually with CT scans. This approach is known as active surveillance or observation.

    If the cancer starts to grow quickly or cause symptoms, active treatment will be recommended.

    Surgery

    Surgery to remove kidney cancer when the cancer has spread is called cytoreductive surgery. This can involve removing the primary cancer in the kidney by nephrectomy, or removing some or all of the tumours that have spread (metastasectomy).

    Recent studies suggest that treatment with targeted therapy alone is as effective as surgery followed by targeted therapy, and many people with advanced kidney cancer are now managed with targeted therapy alone. Cytoreductive nephrectomy may still be offered in certain circumstances, such as when the kidney cancer is causing symptoms, or in people who have very little cancer spread outside the kidney. Generally, surgery is not recommended if you are unwell or if the cancer has spread to many places in the body.

    Targeted therapy

    This is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. The type of targeted therapy most frequently used to treat advanced kidney cancer is a group of drugs called small molecule inhibitors. These drugs can get inside cancer cells and block certain enzymes and proteins that tell cancer cells to grow, multiply and spread.

    Most small molecule inhibitors are in the form of tablets that you take at home. They are commonly given in repeating cycles, with rest periods in between. Some may be taken daily for many months or even years. How long you take the drugs will depend on the aim of the treatment, how the cancer responds, and the side effects you have.

    The two main types of small molecule inhibitors used for advanced kidney cancer in Australia are:

    • Tyrosine kinase inhibitors (TKIs) – these drugs block a group of enzymes called tyrosine kinases from sending signals that tell cancer cells to grow. Without this signal, the cancer cells die. The main TKIs used are sunitinib, pazopanib, cabozantinib, sorafenib and axitinib.
    • mTOR inhibitors – these drugs block mammalian target of rapamycin (mTOR), an enzyme that tells cancer cells to grow and spread. Everolimus is an mTOR inhibitor approved for use for some types of advanced kidney cancer that have not responded to TKIs.

    The Pharmaceutical Benefits Scheme (PBS) subsidises the cost of these targeted therapy drugs as long as certain criteria are met. Medicines or treatments that are not on the PBS are usually very expensive unless given as part of a clinical trial. Cancers often become resistant to particular targeted therapy drugs. If this happens, your doctor will usually suggest trying another targeted therapy drug or another treatment.

    Side effects of targeted therapy

    Ask your doctor what side effects you may experience and how long your treatment will last. Targeted therapy drugs minimise harm to healthy cells, but can still cause side effects. These vary depending on the drug used and how your body responds, but may include fatigue, mouth ulcers, changes in appetite, fevers, allergic reactions, skin rashes, diarrhoea, blood-clotting issues and blood pressure changes.

    For more information about targeted therapy, call Cancer Council 13 11 20 or you can download our fact sheet Understanding Targeted Therapy.

    Immunotherapy

    Immunotherapy is a type of cancer drug treatment that focuses on using the body’s own immune system to fight cancer. Some cancer cells create barriers known as “checkpoints” to block the immune system. Drugs called checkpoint inhibitors help make the cancer cells visible to the body’s own immune system. Once the barrier is removed, the immune system can recognise and destroy the cancer.

    Nivolumab is a checkpoint inhibitor used to treat advanced kidney cancer. Nivolumab is usually administered into a vein (intravenously). It has been shown to be effective in people with advanced kidney cancer previously treated with a tyrosine kinase inhibitor.

    Clinical trials are testing checkpoint immunotherapy at many stages of kidney cancer – after surgery (adjuvant treatment), as the first treatment for advanced kidney cancer, and in combination with existing kidney cancer drugs. In particular, using nivolumab combined with ipilimumab, has been shown to be an effective first treatment for advanced kidney cancer. This combination of drugs is not currently subsidised on the PBS for kidney cancer, however, this may change in the future.

    Side effects of immunotherapy

    The side effects of immunotherapy can vary – not everyone will experience the same effects. Common side effects include fatigue, skin rash and diarrhoea. Because immunotherapy drugs stimulate the immune system, they can cause reactions such as dermatitis, hepatitis and colitis.

    For more information about immunotherapy, call Cancer Council 13 11 20 or you can download our fact sheet Understanding Immunotherapy.

    Radiation therapy

    Radiation therapy uses a controlled dose of radiation, such as focused x-ray beams, to kill or damage cancer cells. It is also known as radiotherapy. Radiation therapy might be used in advanced kidney cancer to shrink a tumour and relieve symptoms.

    If you have radiation therapy, you will lie on a treatment table under a machine called a linear accelerator. You will not feel anything during the treatment, which will only take a few minutes. Each session may last 10–20 minutes because of the time it takes to set up the equipment. You will be able to go home once the session is over.

    The total number of treatment sessions depends on your situation. You might have some side effects, such as fatigue, nausea, appetite loss, diarrhoea, tiredness and skin irritation. Talk to your radiation oncologist about any side effects you experience so you can get advice about how to manage them.

    For more information about radiation therapy, call Cancer Council 13 11 20 or you can download our booklet Understanding Radiation Therapy.

    Palliative treatment

    In some cases of advanced kidney cancer, the medical team may talk to you about palliative treatment. Palliative treatment helps to improve people’s quality of life by managing the symptoms of cancer without trying to cure the disease. It is best thought of as supportive care.

    Many people think that palliative treatment is for people at the end of their life, but it may be beneficial for people at any stage of advanced kidney cancer. It is about living for as long as possible in the most satisfying way you can. Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical, spiritual and social needs.

    As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include radiation therapy to reduce pain from cancer that has spread to the bone, arterial embolisation (a procedure that blocks the blood supply to the kidney and the tumour inside it), targeted therapy or immunotherapy.

    For more information about radiation therapy, call Cancer Council 13 11 20 or you can download our booklet Understanding Palliative Care.

    This website page was last reviewed and updated November 2019

    Information reviewed by: A/Prof Manish Patel, Urological Cancer Surgeon, University of Sydney and Westmead and Macquarie University Hospitals, NSW; Annie Angle, Cancer Nurse, Cancer Council VIC; Lyn Bland, Consumer; Gregory Bock, Cancer Nurse Coordinator (Urology), WA Cancer and Palliative Care Network; Prof Ian Davis, Professor of Medicine and Head of Eastern Health Clinical School, Faculty of Medicine and Nursing and Health Science, Monash University and Senior Medical Oncologist, Eastern Health, VIC; Karen Hall, Clinical Nurse, Cancer Services Division, Flinders Medical Centre and Nurse Health Counsellor, Cancer Council SA; and Frank Hughes, Helpline – Cancer Information and Support, Cancer Council QLD.

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