Let's Talk About Kidney Cancer Treatment
From active surveillance to drug therapy, there are many ways to tackle kidney cancer. Check out HealthCentral's guide to the latest approaches for staying one step ahead of this disease.by Lexi Krupp Health Writer
If you have kidney cancer, there are multiple procedures and medications available to help you. Figuring out which treatment plan is best is the job of your medical care team, which often includes often a urologist, a kidney cancer surgeon, and possibly a medical oncologist. They’ll consider your age and underlying health, the type of cancer you have, and how far it’s advanced to figure out the best way to proceed for the most successful outcome. We’ll run through all the treatments available, but first, let’s go over some kidney cancer basics.
Our Pro Panel
We went to some of the nation's top experts in kidney cancer to bring you the most up-to-date information possible.
Pedro Barata, M.D.
Tulane Cancer Center
New Orleans, LA
Benjamin Chung, M.D.
Director of Robotic Surgery and Urologic Oncologist
Stanford University Medical Center
Ithaar Derweesh, M.D.
UC San Diego Health
San Diego, CA
In patients whose tumors are only found in their kidney, some 20% to 30% will relapse after surgery, usually within three years of treatment. Most often, tumors pop back up in the lung.
This isn’t a primary treatment for kidney cancer but it can be used along with other therapies to control symptoms and ease pain when cancer has spread or when surgery isn’t an option.
Unlike many other cancers, kidney tumors generally don’t respond to chemotherapy. But for people with urothelial carcinoma (when cancer forms in the part of the kidney that collects pee, usually treated like bladder cancer), Wilms tumor (the most common type of kidney cancer in young kids), and some rare forms of the disease, chemotherapy can be part of treatment.
These are research studies that test if new treatments are safe and effective. If you’re enrolled, you might receive the standard treatment or be part of the first wave of patients to try a new therapy. They’re not for everyone, but if your current treatment protocol isn’t working, you can ask your doctor if you are a good candidate for any ongoing clinical trials.
What Is Kidney Cancer, Again?
First, some numbers. Kidney cancer affects about half a million Americans; 70,000 people are diagnosed with some form of the disease every year. More than 75% of people with the disease live for at least five years after diagnosis, although survival rates depend heavily on the stage of the cancer when you are diagnosed.
In a nutshell, kidney cancer is cancer that originates in your kidneys—two potato-shaped organs that sit behind your belly on either side of the spine. They filter your blood—straining out salt, water, and other chemicals—and turn the waste into pee.
This blood-cleaning action takes place in tiny pipes called tubules inside each kidney, and that’s where the trouble with cancer usually pops up. In about nine out of 10 kidney cancer patients, the cancer begins when a mass forms in these blood-filtering tubes.
Depending on a tumor’s size and appearance, and your underlying health, your healthcare team can assess what sort of treatment is needed.
Stages of Kidney Cancer
The treatment you’ll get for this disease depends on what’s known as its stage. To figure this out, clinicians will run imaging tests—typically a CT scan or MRI—to get a better look at a suspicious lump. Usually, they can suss out if it’s cancer from an image, but sometimes they’ll do a biopsy (extracting a piece of the tumor with a needle) to make sure. The size and spread of a tumor determine its stage and this, in turn, informs your medical team how best to manage the disease. Here’s how doctors break up those stages:
Stage 1: If a tumor is small, under 7 cm (or just under 3 inches) and only found in the kidney.
Stage 2: When a tumor grows over 7 cm, but still doesn’t extend past the kidney.
Stage 3: Once a tumor has spread to nearby veins or tissues.
Stage 4: If cancer cells move outside of the kidney, also called metastatic cancer.
Kidney Cancer Treatment Options
Depending on what your doctors find out about how far your cancer has progressed, you and your medical team will discuss one of several treatment approaches, ranging from non-invasive procedures to surgery to drug therapy. Let’ start with two types of less-invasive treatment options you and your medical team may consider.
Most kidney cancers don’t cause symptoms—doctors typically find small tumors in the kidney by chance, often in elderly patients. And many tumors progress at a slow rate. Because of this, monitoring a tumor’s growth with imaging tests every few months can be the best option to start off. This usually means coming in for testing every three to six months for the first two years following your diagnosis. It’s not the right option for everyone, and depends on the type of kidney cancer you have, but here are the situations typically best suited for active surveillance:
Tumors under a few centimeters (especially under 2 cm) and confined to the kidney
Patients over the age of 75
People with other chronic conditions that make surgery to remove a tumor risky
It might sound weird to watch and wait if you have kidney cancer, but many small tumors grow only a few millimeters a year, and some don’t grow at all. It’s the few small tumors that balloon quickly that doctors have to look out for. Those require more proactive treatment.
For people who are not good candidates for surgery because of another medical condition or age, a less invasive medical procedure known as thermal ablation, or using extreme heat or cold to eradicate a tumor, can be a feasible alternative.
This procedure is only appropriate for small tumors (typically under 3 cm) that are confined to the kidney and aren’t too close to other organs or the main blood vessels in the kidney. It’s important to realize this approach comes with a greater likelihood of a tumor coming back compared to surgery and requires follow up imaging tests. But unlike surgery, thermal ablation uses local anesthesia, and can often be performed in an outpatient center, with limited recovery time.
Here are two ways to zap off a tumor:
Cryotherapy: This destroys a tumor by freezing the cancer cells. Clinicians insert a thin probe into the tumor that pumps in liquid nitrogen or liquid argon. This is either done through several small incisions using a camera (called a laparoscope) or with a needle, often depending on the size of the tumor.
Radiofrequency ablation (or RFA): Instead of freezing the tumor, RFA roasts it. Here, a thin probe heats a tumor to over 112 degrees F with high-energy radio waves, killing the cancer cells and surrounding tissue. Doctors might use an ultrasound, CT scan, or MRI to guide the needle to the tumor.
What Is a Nephrectomy?
For kidney cancers that haven’t spread to other organs, surgery to remove some or all of the kidney, called a nephrectomy, is the standard of care. And even if cancer has spread outside the kidney, patients might still have surgery to help relieve symptoms, like pain from a large tumor, high blood pressure, too much calcium in the blood, internal bleeding, and weakness.
Surgery to remove a kidney tumor falls into two groups: partial nephrectomy (removal of some of the kidney) or radical nephrectomy (removal of the whole organ) and depends on the size and complexity of the tumor.
Only in the last 30 years has this method emerged to remove some of the kidney, instead of taking out the whole organ. Patients who undergo this procedure have the great benefit of retaining some kidney function. But because of the size and positioning of a tumor, it’s not always possible to take out just a chunk of the kidney.
For patients who have easy-to-extract tumors or those whose kidney function might be compromised if left with only one kidney, it’s the treatment of choice. These are some of the cases when a partial nephrectomy would be preferred:
Impaired kidney function, or only one kidney to begin with
Multiple tumors in the kidney
Chronic conditions that could impact kidney function down the road, like high blood pressure, diabetes, or obesity
Genetic conditions that make it more likely for tumors to come back, like Von Hippel-Lindau disease
For some patients, removing the whole kidney might be the best option—like when gutting a house is easier than a repair. If a tumor is large and complex, say it extends into a major vein, removing just a piece of the kidney might not be viable. Typically, a radical nephrectomy includes taking out a fatty layer surrounding the kidney, nearby lymph nodes, and the adjoining adrenal gland.
The good thing about your kidneys is that they function independently of one another, so you can be perfectly healthy with only one. But if both kidneys need to be removed, or the remaining kidney is damaged, you’ll need dialysis (using a machine to clean the blood) or a kidney transplant.
Unfortunately, a radical nephrectomy comes with an increased risk for chronic kidney disease and has been associated with heart disease in some studies.
How Are Surgeries Performed?
If your medical team decides it’s best to remove your kidney, surgery will involve one of two techniques. Which one depends on how big the tumor is and where it’s located:
Open surgery: This is the traditional method of operating, where surgeons work through one main incision to extract a tumor.
Minimally invasive surgery: In this approach, surgeons operate through several small incisions using a long instrument with a camera on its end called a laparoscope. Some use robotic assistance to perform these operations (known as robotic-assisted laparoscopic surgery).
After minimally invasive surgeries, patients typically have a faster recovery time, fewer complications, and need less pain medication. But these operations are more costly, take longer, and require extensive experience and expertise. What’s more, some tumors are better suited for one type of surgery than the other, depending on how they sit in the body.
What Drug Therapies Are Available for Kidney Cancer?
If cancer has spread beyond the kidneys, medications are typically the mainstay treatment. A surge of new therapies has emerged in recent years, so there are a lot of options out there. Note that most of these drugs have been tested to treat clear cell renal cell carcinoma—the most common kidney cancer—but often not other kidney cancers.
Immunotherapy (Biologic Therapy)
This class of drugs uses your body’s immune system to fight against cancer. There are a number of different types of biologic therapies, which are often paired together:
Immune checkpoint inhibitors: Certain cancer cells are outfitted with something called checkpoint proteins on their surface. T cells, a type of immune cell, also have these checkpoint proteins. This allows sneaky cancer cells to disguise themselves as T cells and avoid attacks from your immune system. The way these drugs work is to block the cancer cells from producing the checkpoint proteins so they can no longer hide from attacks. Here are the immune checkpoint inhibitors approved to treat clear cell renal cell carcinoma:
Yervoy (ipilimumab), often used in conjunction with Opdivo
Interferons (IFNs): This is a substance that your immune system makes that can slow tumor growth. This class of drugs is no longer used as a primary treatment for kidney cancer—it is used only in conjunction with Avastin (bevacizumab), a type of targeted therapy.
Interleukin-2 (IL-2): This is a synthetic form of a protein in your body that produces more immune cells, particularly a type of white blood cell called lymphocytes that attack cancer cells. However, only about 10% of patients respond to this drug at high doses, and it causes significant toxic side effects.
Side effects of biologic therapies: Since these drugs stimulate the immune system, they can cause a wide range of side effects from rashes to fever, fatigue, heart disease, diarrhea, and shortness of breath.
These drugs attack cancer cells while limiting harm to healthy cells and are often paired with immunotherapies for maximum effect. They operate by either blocking blood vessels from forming in a tumor (something called angiogenesis) or by limiting certain proteins that help cancer cells grow, divide, and survive (called tyrosine kinases). Here’s how they work:
VEGF inhibitors: Cancer cells produce a protein called vascular endothelial growth factor, or VEGF, that cause new blood vessels to form, effectively feeding a tumor. (Normal cells also produce this protein, but in smaller amounts.) These drugs (given by IV or orally) block this action.
Avastin or Mvasi (bevacizumab)
Cabometyx or Cometriq (cabozantinib)
mTOR inhibitors: mTOR is a protein that helps control cell division and survival, and is often more active in cancer cells than normal cells. Aptly named, mTOR inhibitors (given orally or by IV) block this protein to halt cancer cells growth.
Afinitor, Afinitor Disperz, or Zortress (everolimus)
Side effects of targeted therapies: These drugs come with a range of side effects, including nausea, diarrhea, high blood pressure, vomiting, fatigue and weakness, and other, more serious, symptoms.
Dealing With Life During Treatment
There’s nothing easy about a kidney cancer diagnosis, and there’s nothing simple about getting through treatment, either. That said, the growing number of treatment options and diversity in medication is making is more possible than ever before to receive treatment while still living some semblance of your normal life.
There may be days when you feel too wiped out to do anything, and other days when you feel ill from the side effects of treatment. Recovering from surgery will also take time and patience. Cut yourself some slack, and when possible, enlist friends and family to help with the everyday tasks like shopping, cleaning, and cooking.
And before committing to any treatment, talk with your doctor and medical team to make sure you understand the options available and why this is the best path forward. Knowing the reasons can reassure you that you are doing the right thing for your health and your future.
- Active Surveillance: European Urology Oncology. (2018). “Role of Active Surveillance for Localized Small Renal Masses.” ncbi.nlm.nih.gov/pubmed/31102618
- Cryotherapy: (2018). RöFo. “Current Technique and Application of Percutaneous Cryotherapy.” ncbi.nlm.nih.gov/pubmed/29665588
- Surgery: Future Oncology. (2016). “Emerging surgical treatments for renal cell carcinoma.” europepmc.org/article/med/26892144
- FDA-Approved Drugs: National Cancer Institute. (2020). “Drugs Approved for Kidney (Renal Cell) Cancer.” cancer.gov/about-cancer/treatment/drugs/kidney
- Kidney Cancer Treatment Guidelines: American Urological Association (2017). “Renal Mass and Localized Renal Cancer: AUA Guideline.” auanet.org/guidelines/renal-cancer-renal-mass-and-localized-renal-cancer-guideline
- Treatment Guidelines: Journal of the National Comprehensive Cancer Network. (2017). “Kidney Cancer, Version 2.2017, NCCN Clinical Practice Guidelines in Oncology.” jnccn.org/view/journals/jnccn/15/6/article-p804.xml
- Treatment: National Cancer Institute. (2020). “Renal Cell Cancer Treatment” cancer.gov/types/kidney/patient/kidney-treatment-pdq#_1
- Drug Therapy: The Lancet. (2016). “Renal Cancer.” ncbi.nlm.nih.gov/pubmed/26318520
- Drug Resistance: Urological Oncology. (2017). “Strategies to Overcome Therapeutic Resistance in Renal Cell Carcinoma.” ncbi.nlm.nih.gov/pmc/articles/PMC5318278/