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Treatment for kidney cancer
Treatment for early kidney cancer
Early kidney cancer (stage 1 or 2) is localised. That means the cancer is found in the kidney only or has not spread very far. The main treatment is surgery. Less often, radiofrequency ablation, cryotherapy and stereotactic body radiation therapy are used. Sometimes the best approach for early kidney cancer is to watch the cancer over time (active surveillance).
Also known as observation, active surveillance is a way of monitoring kidney cancer. The aim is to avoid affecting how your kidney works and other side effects you may experience if you have surgery. It may be suggested if the tumour is less than 4 cm in diameter. Active surveillance might also be an option if you are not well enough for surgery and the tumours are small, or if you are older.
Active surveillance involves having regular ultrasounds or CT scans. If these imaging tests suggest that the tumour has grown, you may be offered active treatment (usually surgery).
Choosing active surveillance avoids treatment side effects, but you might feel anxious about having a cancer diagnosis without active treatment. Talk to your doctors about ways to manage any worries.
Surgery is the main treatment for early kidney cancer. Depending on the type of kidney cancer, the grade and stage of the cancer, and your general health, you might have one of the operations described below.
Partial nephrectomy – This is the most common operation for tumours 7 cm or smaller that are found only in the kidney. It may also be used for people who have existing kidney disease, cancer in both kidneys or only one working kidney.
Only the cancer and a small part of the surrounding kidney are removed.
A partial nephrectomy is a more difficult operation than a radical nephrectomy. Whether it is possible depends on where the tumour is in the 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 large vein that takes blood to the heart. Even if the cancer has spread to 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 does the work of both kidneys. Your doctor will talk to you about how to keep the remaining kidney healthy, which may include reducing your risk of high blood pressure, heart problems and diabetes.
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.
One of the following methods will be used to remove part or all of the kidney (partial or radical nephrectomy). Each method is suitable in particular situations.
Open surgery – This is usually done with a long cut (incision) 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 and divide the major blood vessels and tubes to the affected kidney before removing it.
Keyhole surgery – This is also called minimally invasive surgery or laparoscopic 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 openings. The laparoscope sends images of your body to a video monitor. The surgeon watches the images on the monitor for guidance during the operation.
Robot-assisted surgery – This is a type of keyhole surgery using a robotic device. The surgeon sits at a control panel to see a three-dimensional image and moves robotic arms that hold the instruments. Robotic surgery has allowed more partial nephrectomies to be performed with keyhole surgery, reducing complications and improving recovery time.
What to expect after surgery
After surgery, you will usually be in hospital for 2–7 days. Once you are home, you will need to take some precautions while you recover. Your recovery time will depend on your age, general health and the type of surgery that you had.
Drips and tubes – While in hospital, you will be given fluids and medicines via a tube inserted into a vein (intravenous drip). You will also have other temporary tubes to drain waste fluids away from the operation site.
For a few days, you will most likely have a thin tube inserted in your bladder that is attached to a bag to collect urine. This is called a urinary catheter. Knowing how much urine you are passing helps hospital staff monitor how the remaining kidney is working (functioning). When the catheter is removed, you will be able to urinate normally again.
Pain relief – You will have some pain in the areas where the cuts in the skin were made and where the kidney (or part of the kidney) was removed.
If you are in pain, ask for medicine to help control it. You might have an anaesthetic injected into the area around your spine (epidural), painkillers injected into a vein or muscle, or a patient-controlled analgesia (PCA) system. The PCA system delivers a measured dose of pain medicine when you push a button.
Blood clots – You will usually have to wear compression stockings to help the blood in your legs circulate and prevent blood clots developing.
Moving around – Your health care team will probably encourage you to walk the day after the surgery.
You may see a physiotherapist while you are in hospital. They can explain the safest way to move and show you exercises to do while you are recovering. These might include breathing or coughing exercises that can help you avoid developing a chest infection.
It will be some weeks before you can lift heavy things, reach high with your arms or drive. Ask your doctor how long you should wait before attempting any of these activities or returning to work.
Returning home – When you get home, you will need to take things easy and only do what is comfortable. Let your family and friends know that you need to rest a lot and might need some help around the house. Try to eat a balanced diet (including proteins such as lean meats and poultry, fish, eggs, milk, yoghurt, nuts, seeds and legumes or beans) to help your body recover from surgery.
Check-ups – You will need to visit the hospital for a check-up a few weeks after you’ve returned home.
If you are not well enough for surgery and the tumour is small, other treatments to destroy or control the cancer may be recommended.
Radiofrequency ablation (RFA) – This procedure uses high-energy radio waves to heat the tumour. The heat kills the cancer cells and forms internal scar tissue. 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. RFA 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.
Cryotherapy – Also known as cryosurgery, cryotherapy kills cancer cells by freezing them. This treatment is not widely used in Australia. Under a general anaesthetic, a cut is made in the abdomen. The doctor inserts a probe through the cut into the tumour. The probe gets very cold, which freezes and kills the cancer cells. Cryotherapy takes about 60 minutes. Side effects include bleeding and leaking urine.
Stereotactic body radiation therapy (SBRT) – This is also called stereotactic ablative body radiation therapy (SABR) and is a specialised form of radiation therapy. It is a way of giving a highly focused dose of radiation therapy to a primary kidney cancer when surgery is not possible due to other health conditions. SBRT is painless and is usually delivered over one to three days.
Treatment for advanced kidney cancer
When kidney cancer has spread outside the kidney to lymph nodes or other parts of the body (stage 3 or 4), it’s known as advanced or metastatic cancer. The aim of treatment is to slow the spread of the cancer and to manage any symptoms.
A combination of different treatments may be recommended. Which combination is suitable for you will depend on several factors, including how soon after diagnosis you start systemic treatment, blood counts, blood calcium levels and your general health.
Drugs that reach cancer cells throughout the body are called systemic treatments. These can include chemotherapy, targeted therapy and immunotherapy.
Targeted therapy and immunotherapy are the main systemic treatments used to control advanced kidney cancer. The types of drugs and combinations used are rapidly changing as clinical trials show better responses and improved survival with newer drugs. Since the development of these more effective systemic treatments, chemotherapy is rarely used for kidney cancer.
Talk with your doctor about the latest developments and whether you are a suitable candidate. Ask them about the side effects you might have. Most side effects can be managed, and treating them early is likely to reduce how long side effects last.
The Pharmaceutical Benefits Scheme (PBS) subsidises the cost of targeted therapy or immunotherapy 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.
In some cases, kidney cancer grows so slowly that it won’t cause any problems for a long time. Because of this, especially if the advanced kidney cancer has been found unexpectedly, your doctor may suggest looking at the cancer regularly, 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.
This is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. The main groups of targeted therapy drugs for advanced kidney cancer are tyrosine kinase inhibitors (TKIs) and mTOR inhibitors. These drugs can get inside cancer cells and block certain enzymes and proteins that tell cancer cells to grow, multiply and spread.
Targeted therapy drugs are usually used as the first treatment for advanced kidney cancer (first-line treatment).
Kidney cancer often stops responding to particular targeted therapy drugs. If this happens, your doctor will usually suggest another targeted therapy drug or immunotherapy combination. Research shows that having targeted therapy drugs together with immunotherapy has led to better response rates in certain people.
Tyrosine Kinase Inhibitors (TKIs)
How they work – 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
When they are used – approved for use in some types of advanced kidney cancer
How they are given – taken as daily tablet; often given in repeating cycles, with rest periods in-between; some may be taken for many months or even years
Examples (may also be known by their brand name) – sunitinib, pazopanib, cabozantinib, sorafenib, axitinib, lenvatinib
Side effects – fatigue, mouth ulcers, changes in appetite, fevers, allergic reactions, skin rashes, diarrhoea, blood-clotting issues, blood pressure changes
How they work – drugs block the mammalian target of rapamycin (mTOR), an enzyme that tells cancer cells to grow and spread
When they are used – approved for use for some types of advanced kidney cancer that have not responded to TKIs
How they are given – taken as daily tablet; may be taken for many months or even years; may be given alone or with a TKI
Examples (may also be known by their brand name) – everolimus
Side effects – diarrhoea, fatigue, skin rash, mouth sores, high blood sugar
There have been many advances in treating advanced kidney cancer with immunotherapy drugs known as checkpoint inhibitors. These use the body’s own immune system to fight cancer.
Checkpoint inhibitors approved to treat advanced kidney cancer include ipilimumab and nivolumab. The drugs are usually given into a vein (intravenously). Taking these drugs together has been shown to work well as a first-line treatment for advanced kidney cancer. In people with advanced kidney cancer previously treated with a tyrosine kinase inhibitor, nivolumab has been shown to work well as a second-line treatment.
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 together with existing kidney cancer drugs, such as in combination with TKIs. Clinical trials are also testing new types of immunotherapy and targeted therapy drugs.
Side effects of immunotherapy
The side effects of immunotherapy can vary – not everyone will experience the same effects. Immunotherapy can cause inflammation in any of the organs of the body, leading to side effects such as fatigue, skin rash and diarrhoea. The inflammation can lead to more serious side effects in some people, but this will be monitored closely and managed quickly.
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 may also be used in advanced kidney cancer to shrink a tumour and relieve symptoms such as pain and bleeding (palliative treatment).
If you have radiation therapy, you will lie on a treatment table under a machine called a linear accelerator. The treatment is painless and takes only a few minutes. Each session usually lasts for 10–20 minutes. You will be able to go home once the session is over, and in most cases you can drive afterwards.
The total number of treatment sessions depends on your situation. You might have some temporary side effects, such as fatigue, nausea, loss of appetite, diarrhoea, tiredness and skin irritation. The radiation oncologist can talk to you about side effects you are likely to experience and give you advice about how to manage them.
Surgery to remove kidney cancer that has spread is known as 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 is as effective as targeted therapy combined with cytoreductive surgery.
Cytoreductive nephrectomy may be offered when the kidney cancer is causing symptoms, or when there is very little cancer spread outside the kidney. It can also be used in some people who have responded well to systemic treatment. Generally, surgery is not recommended if you are unwell or if the cancer has spread to many places in the body.
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 aims to meet your physical, emotional, cultural, spiritual and social needs.
As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatments may include radiation therapy, arterial embolisation (a procedure that blocks the blood supply to the tumour) to reduce blood in the urine, targeted therapy or immunotherapy.
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This information is reviewed by
This information was last reviewed November 2020 by the following expert content reviewers: A/Prof Daniel Moon, Urologic Surgeon, Australian Urology Associates, and Honorary Clinical Associate Professor, The University of Melbourne, VIC; Polly Baldwin, 13 11 20 Consultant, Cancer Council SA; Ian Basey, Consumer; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer and Palliative Care Network, North Metropolitan Health Service, WA; Tina Forshaw, Advanced Practice Nurse Urology, Canberra Health Services, ACT; Dr Suki Gill, Radiation Oncologist, Sir Charles Gairdner Hospital, WA; Karen Walsh, Nurse Practitioner, Urology Services, St Vincents Private Hospital Northside, QLD; Dr Alison Zhang, Medical Oncologist, Chris O’Brien Lifehouse and Macquarie University Hospital, NSW.