After the cancer is found and staged, your cancer care team will discuss your treatment options with you. It is important to take time and think about your possible choices. In choosing a treatment plan, one of the most important factors is the stage of the cancer. Other factors to consider include your overall health, the likely side effects of the treatment, and the probability of curing the disease, extending life, or relieving symptoms. If you have kidney cancer, your treatment options may include:
• Active surveillance
In some cases, especially when the cancer is small and slow-growing, the doctor may recommend that the patient is monitored closely and wait to start active treatment until there is evidence that the disease is worsening. This approach is called active surveillance, watchful waiting, or watch-and-wait.
• Arterial embolization
Arterial embolization is a type of local therapy that shrinks the tumor. Sometimes it is done before an operation to make surgery easier. When surgery is not possible, embolization may be used to help relieve the symptoms of kidney cancer.
The doctor inserts a narrow tube (catheter) into a blood vessel in the leg. The tube is passed up to the main blood vessel (renal artery) that supplies blood to the kidney. The doctor injects a substance into the blood vessel to block the flow of blood into the kidney. The blockage prevents the tumor from getting oxygen and other substances it needs to grow.
People may want to ask the doctor these questions before having arterial embolization:
- Why do I need this procedure?
- Will I have to stay in the hospital? How long?
- What are the risks and side effects?
- Would a clinical trial be appropriate for me?
• Biological therapy
Biological therapy is a type of systemic therapy. It uses substances that travel through the bloodstream, reaching and affecting cells all over the body. Biological therapy uses the body's natural ability (immune system) to fight cancer.
For patients with metastatic kidney cancer, the doctor may suggest interferon alpha or interleukin-2 (also called IL-2 or aldesleukin). The body normally produces these substances in small amounts in response to infections and other diseases. For cancer treatment, they are made in the laboratory in large amounts.
• Chemotherapy
Chemotherapy is also a type of systemic therapy. Anticancer drugs enter the bloodstream and travel throughout the body. Although useful for many other cancers, most anticancer drugs have shown limited use against kidney cancer. However, many doctors are studying new drugs called targeted agents used wither alone or in new combinations that may prove more helpful. The section on "The Promise of Cancer Research" has more information about these studies.
• Immunotherapy (biologic therapy)
Immunotherapy (also called biologic therapy) is designed to boost the body's natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Kidney cancer may be one of the few cancers that the body’s immune system can fight, which often makes immunotherapy effective in treating kidney cancer. Immunotherapy may be beneficial in certain patients.
Interleukin-2 (IL-2) is a drug that has been used to treat advanced kidney cancer. It is a cellular hormone called a cytokine that is produced by white blood cells and is important in immune system function, including the destruction of tumor cells.
High-dose 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, so patients may need to stay in the hospital for up to 10 days during treatment. However, some symptoms may be reversible. Only centers with expertise in high-dose IL-2 for kidney cancer should recommend IL-2. Some centers use low-dose IL-2 because it has fewer side effects, although it is not as effective.
Alpha-interferon is another type of immunotherapy used to treat kidney cancer that has spread. Interferon appears to change the proteins on the surface of cancer cells and slow their growth. Although it has not proven to be as beneficial as IL-2, it has been proven to increase survival when compared with an older treatment called megestrol acetate. Researchers have tested many combinations of IL-2 and alpha-interferon for patients with advanced kidney cancer, and these treatments have also been combined with chemotherapy. It has not been shown in research studies that these combinations are better than IL-2 or interferon alone.
Researchers are working to learn more about how IL-2 and interferon fight kidney cancer and which patients can benefit the most from these treatments.
• Radiation therapy
Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.
Radiation therapy is not considered effective as a primary treatment for kidney cancer. It is used alone only rarely to treat kidney cancer because of the high rate of damage that it causes to the healthy kidney. It is used only if a patient cannot have surgery and, even then, usually only on areas where the cancer has spread and not the primary kidney tumor. Most often, radiation therapy is used after the cancer has spread to help ease symptoms, such as bone pain or swelling in the brain.
The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. For kidney cancer, internal radiation therapy is given using a hollow needle to insert radioactive seeds directly into a tumor. Another type of radiation therapy is stereotactic radiosurgery, which is designed to direct the radiation therapy to a specific area without damaging nearby tissue. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time.
Side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Internal radiation therapy may cause some bleeding, infection, and risk of injury to nearby tissue. Most side effects go away soon after treatment is finished.
• Surgery
Surgery is the removal of the tumor and surrounding tissue during an operation. If the cancer has not spread beyond the kidneys, surgery to remove the tumor, part or all of the kidney, and possibly nearby tissue and lymph nodes, may be the only treatment necessary. A urologist or urologic oncologist is a doctor who specializes in treating kidney cancer using surgery. The types of surgery used for kidney cancer include the following procedures:
- Cryoablation (also called cryotherapy or cryosurgery) is the freezing of cancer cells with a metal probe inserted through a small incision. The metal probe is placed into the cancerous tissue using a CT scan and ultrasound as guidance. The procedure requires general anesthesia for several hours. The U.S. Food and Drug Administration (FDA) approved this treatment for kidney cancer, but more research studies are needed to determine how effective this treatment is in the long term.
- Laparoscopic and robotic surgery. In laparoscopic surgery, the surgeon makes several small incisions, instead of the one larger incision in the abdomen used in traditional surgery. Then the surgeon inserts telescoping equipment into these small, keyhole incisions to remove the kidney completely or perform a partial nephrectomy. In some instances, the surgeon may use robotic instruments to perform the operation. This surgery may take longer, but it is less painful afterward and patients recover more quickly. It is important to discuss the potential benefits and risks of these types of surgery with the surgical team.
- Partial nephrectomy. The surgeon removes only the part of the kidney that contains the tumor. This type of surgery may be used when the person has only one kidney, or when the cancer affects both kidneys. Also, a person with a small kidney tumor (less than 4 centimeters) may have this type of surgery.
- Radical nephrectomy. Kidney cancer is usually treated with radical nephrectomy. The surgeon removes the entire kidney along with the adrenal gland and some tissue around the kidney. Some lymph nodes in the area also may be removed.
- Radiofrequency ablation (RFA) is the use of a needle inserted into the tumor to destroy the cancer with an electrical current. The procedure is performed by a radiologist or urologist (a doctor specializing in the urinary tract). The patient is sedated and given local anesthesia to numb the area.
- Simple nephrectomy. The surgeon removes only the kidney. Some people with Stage I kidney cancer may have a simple nephrectomy.
• Targeted therapy
Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells. These drugs are becoming more important in the treatment of kidney cancer.
Recent studies show that not all tumors have the same targets. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them.
Anti-angiogenesis therapy is a type of targeted therapy used in kidney cancer treatment. It is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor.
For clear cell kidney cancer, sunitinib (Sutent), pazopanib (Votrient), and sorafenib (Nexavar), called tyrosine kinase inhibitors (TKIs), are two anti-angiogenic drugs that may be used during treatment. Clear cell kidney cancer has a mutation of the VHL gene that causes the cancer to make too much of a certain protein, known as vascular endothelial growth factor (VEGF). VEGF controls the formation of new blood vessels. Axitinib (Inlyta), also a TKI, has been approved to treat advanced renal cell carcinoma. Side effects of TKIs may include diarrhea, high blood pressure, and tenderness and sensitivity in the hands and feet.
Another anti-angiogenic drug, bevacizumab (Avastin), has been shown to slow tumor growth for people with metastatic renal carcinoma. Bevacizumab combined with interferon (see below) slows tumor growth and spreading.
Temsirolimus (Torisel) and everolimus (Afinitor) are drugs that attack a certain protein that helps kidney cancer cells grow, called mTOR. Studies show that these drugs slow kidney cancer growth.
You may have different types of doctors on your treatment team, depending on the stage of your cancer and your treatment options. These doctors could include:
- A urologist: a surgeon who specializes in treating diseases of the urinary system (and male reproductive system)
- A radiation oncologist: a doctor who treats cancer with radiation therapy
- A medical oncologist: a doctor who treats cancer with medicines such as chemotherapy
Many other specialists might be part of your treatment team as well, including physician assistants, nurse practitioners, nurses, physical therapists, social workers, and other health professionals. It’s important to discuss all of your treatment options as well as their possible side effects with your doctors to help make the decision that best fits your needs. When time permits, getting a second opinion is often a good idea. It can give you more information and help you feel good about the treatment plan you choose.