Kidney cancer is among the 10 most common cancers in the United States. While there are several types, renal cell carcinoma (RCC) is the most common, accounting for up to 90 percent of kidney cancers, according to the Urology Care Foundation. Subtypes include clear cell (80 percent of all RCC), papillary, chromophobe, and collecting duct.
Another type of kidney cancer, accounting for 10 to 15 percent of cases, is urothelial carcinoma, or transitional cell carcinoma. Other kidney cancer types include sarcoma (rare), Wilms tumor (mostly diagnosed in children), and lymphoma.
RCC begins in the lining of the tiny tubes of the kidney. In its early stages, the cancer is confined to the kidney and surrounding tissues. When the cancer spreads, or metastasizes, beyond the kidney and nearby tissue, it is considered to be advanced, or stage IV; about 25 percent of people with kidney cancer are diagnosed at this stage. Common sites for it to spread to are the lungs, bones, and lymph kidney cancer types include sarcoma (rare), Wilms tumor (mostly diagnosed in children), and lymphoma.
RCC begins in the lining of the tiny tubes of the kidney. In its early stages, the cancer is confined to the kidney and surrounding tissues. When the cancer spreads, or metastasizes, beyond the kidney and nearby tissue, it is considered to be advanced, or stage IV; about 25 percent of people with kidney cancer are diagnosed at this stage. Common sites for it to spread to are the lungs, bones, and lymph nodes. But even after kidney cancer has metastasized, there is a lot that doctors can do in order to control symptoms and slow the spread of the disease.
Exams, Labs, and Images
It used to be that abdominal pain or swelling, blood in the urine, or unexplained weight loss were the symptoms that brought people to the doctor when advanced kidney cancer was ultimately diagnosed. More recently, this cancer is often diagnosed when you’re having imaging tests for other reasons—an X-ray for a heart workup, say, or a sports injury. This is a good thing, explains Mollie deShazo, MD, associate professor of hematology and oncology and scientist at the O’Neal Comprehensive Cancer Center at the University of Alabama at Birmingham. “The prognosis is better if the cancer is found incidentally, before symptoms are obvious,” she says.
No matter what your reason for making an appointment, if your doctor suspects you have kidney cancer, they will examine you, do a variety of tests, and take a detailed personal and family health history. They will feel for any masses (possible tumors), and you’ll be asked to give blood and urine samples. A urine test may show if there are small amounts of blood in your urine that you were unable to see, while a blood count may show if you are anemic, among other possible indicators of kidney cancer.
Imaging tests also help diagnose kidney cancer. Computed tomography (CT) scans not only identify tumors in the kidney, but also can provide detailed information about the size, shape, and precise location of the tumors. Ultrasound is also useful in locating kidney tumors. Magnetic resonance imaging (MRI) is ordered if your doctor suspects your cancer has grown into your abdominal blood vessels. You may have a scan to see if the cancer has spread to your bones and a chest X-ray to see if it appears in your lungs. An MRI or CT scan could reveal whether the cancer has metastasized to your brain.
These tests help your doctor determine how advanced your cancer is—a process called “staging” the cancer. Staging helps your team determine the best treatment. It can also predict how you may respond to certain treatments. The higher and more complex the stage, the more aggressive your treatment is likely to be. Sometimes staging can also be used to predict how long you may live. But survival predictions are imperfect because each person is unique and new treatments are quickly changing outcomes.
What happens next depends on the stage of your cancer. If you are diagnosed with advanced kidney cancer, your doctor will need more information to determine the best treatment for you. A complete blood count (CBC) will show your hemoglobin and neutrophil levels and your platelet count, which could indicate anemia or risk of infection or bleeding. Your doctor will also check for calcium in your blood, another possible indicator of cancer. And you’ll be asked how active you are, which activities you’re able to do, and which are difficult for you.
“Based on this information,” says Dr. deShazo, “we’ll assign a prognostic score.” This is essentially a prediction that helps your doctor determine which treatment might be best for you. “Even with advanced kidney cancer, a small percentage of patients won’t need any treatment right away,” she says. “We just watch very carefully. This is called active observance. However, most people will get treated up front.”
Treatment Combo Approach
Several newer therapies are now being used to treat advanced, or stage IV, kidney cancer.
Until about a decade ago, there were few effective treatments for metastatic kidney cancer. But since 2005, advances in immunotherapy and targeted therapies have changed the face of kidney cancer treatment.
“When the cancer has spread, we use systemic therapy. We call it this because we don’t use traditional chemotherapy very often in kidney cancer. Chemo has not been effective in this type of cancer. Instead, we use targeted therapy or immunotherapy,” says urologic oncologist John L. Gore, MD, a professor of urology at the University of Washington School of Medicine in Seattle. Targeted therapy basically starves the cancer. “Targeted therapy interferes with the cancer’s ability to grow new blood cells,” explains Dr. Gore. Targeted therapies for advanced kidney cancer include:
- Axitinib (Inlyta)
- Bevacizumab (Avastin)
- Cabozantinib (Cabometyx)
- Everolimus (Afinitor)
- Lenvatinib (Lenvima)
- Pazopanib (Votrient)
- Sorafenib (Nexavar)
- Sunitinib (Sutent)
- Temsirolimus (Torisel)
Immunotherapy drugs stimulate your immune system to attack cancer cells. “Until about 15 years ago, immunotherapies were nonspecific,” explains Dr. Gore. “The newer drugs are more specific. The latest treatments are immune checkpoint inhibitors.” Certain immune cells (T-cells) must be switched on for the immune system to fight cancer. One of the ways many cancers spread is by overexpressing proteins that help tumor cells hide from the immune system. The cancer basically tricks your immune system into ignoring it. Immune checkpoint inhibitors help activate T cells so that you can fight the cancer. The drug itself doesn’t attack the cancer; it just makes it possible for your immune system to do the work.
Immunotherapies used for kidney cancer include:
- Avelumab (Bavencio)
- Ipilimumab (Yervoy)
- Nivolumab (Opdivo)
- Pembrolizumab (Keytruda)
Cytokines, which boost the immune system generally, are sometimes still used, though not often. They include high-dose interleukin-2 (IL-2) and interferon-alfa. Interferon is sometimes still used in combination with bevacizumab (Avastin). Which drug or combination of drugs you’re given will depend on your prognostic score, says Dr. deShazo. The higher the score, the worse the prognosis.
While single systemic therapies are often effective, sometimes a combination is the most effective way to treat advanced kidney cancer. The targeted therapy denies the tumor the nutrients it needs to thrive, while the immunotherapy helps the immune system tackle the cancer cells.
“If you have risk factors such as high calcium in your blood or anemia, you start with the combo drugs,” Dr. deShazo explains. “For patients with a good (lower) prognostic score, I’ll flip it around, and may start with a single drug, such as pazopanib (Votrient), and go to the combo later. We can even use a new combination regimen with pembrolizumab (Keytruda) and axitinib (Inlyta) for good-prognosis patients now, so we have many options.”
Surgery: Not So Much
In most cases, doctors no longer remove tumors in people with advanced kidney cancer.
“If a patient has metastatic cancer, it’s best to concentrate on the cancer cells throughout the body and leave the original tumor in place,” says Dr. Gore. “It used to be that if we took out the main kidney tumor, patients would do better. But that was in the setting of less effective systemic therapies. As systemic treatments improve, there isn’t as much benefit to removing the kidney. Some patients will do better, but for most, it’s no longer a good idea to do the surgery as the first treatment. We prioritize starting systemic therapy, then consider surgery down the road.”
Once your treatment is done, your doctor will continue to follow you. How often will depend on your cancer stage and treatment. Thanks to treatment advances, your odds of longer survival are much greater now than they would have been just a few years ago.
“Not long ago, survival time with stage IV kidney cancer was about one year. Now, with targeted therapy, the mean survival rate is two-plus years,” says Dr. deShazo. And it might be even better with immunotherapy. “People [who have had this treatment] are still alive, and we don’t yet know how long they’ll live.”
Today’s therapies give people with advanced kidney cancer much reason for optimism.