Kidney Cancer

Treatment Options

This section outlines treatments that are the standard of care (the best proven treatments available) for this specific type of cancer. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new treatment to evaluate whether it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. 

Treatment overview

In cancer care, different types of doctors often work together to create a patient's overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Treatment options and recommendations depend on several factors, including the type and stage of cancer, possible side effects, and the patient's preferences and overall health. 

Kidney cancer is most often treated with surgery, targeted therapy, and/or immunotherapy. Radiation therapy and chemotherapy are occasionally used. Patients with kidney cancer that has spread (advanced cancer, see below) often receive multiple lines of therapy (treatments given one after another). Descriptions of these treatment options are listed below.

Active surveillance

In some cases, especially when the amount of 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.

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:

Radical nephrectomy. Surgery to remove the tumor, the entire kidney, and surrounding tissue is called a radical nephrectomy. If nearby tissue and surrounding lymph nodes are also affected by the disease, a radical nephrectomy and lymph node dissection (removal of the lymph nodes affected by the cancer) is performed. If the cancer has spread to the adrenal gland or nearby blood vessels, the surgeon may remove the adrenal gland (a procedure called an adrenalectomy) and parts of the blood vessels.

Partial nephrectomy. A partial nephrectomy is the surgical removal of a tumor while preserving kidney function and lowering the risk of kidney disease after surgery, called hyperfiltration injury. It is used most often for a small tumor, even when the other kidney functions normally.

Laparoscopic surgery. In laparoscopic surgery, the surgeon makes several small incisions, instead of one larger incision in the abdomen used in traditional surgery. The surgeon uses telescoping equipment to remove the kidney completely or perform a partial nephrectomy. This surgery may take longer, but it is less painful afterward and patients recover more quickly.

Radiofrequency ablation. 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. The patient is sedated and given local anesthesia to numb the area.

Cryoablation. 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.

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 normal cells. These drugs are becoming more important in the treatment of kidney cancer.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. 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.

Talk with your doctor about possible side effects for each specific medication and how they can be managed. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. 

Immunotherapy

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 bolster, 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 commonly 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 normal 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.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells, usually by stopping the cancer cells' ability to grow and divide. Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of different drugs at the same time.

While useful to treat most types of cancer, kidney cancer is often resistant to chemotherapy. Researchers continue to study new drugs and new combinations of drugs. For some patients, the combination of gemcitabine (Gemzar) and fluorouracil (5-FU, Adrucil) or capecitabine (Xeloda) will temporarily shrink a tumor. Also, axitinib may be prescribed to treat advanced renal cell carcinoma. It is important to remember that urothelial carcinoma (also called transitional cell carcinoma) and Wilms tumor are much more likely to be successfully treated with chemotherapy.

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished.

 The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications.

Palliative/supportive care

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person's symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem, so it is addressed as quickly as possible. 

Recurrent kidney cancer

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it's important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. 

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above (such as surgery, targeted therapy, immunotherapy, radiation therapy and chemotherapy) but may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. 

Metastatic kidney cancer

In the most advanced stage (stage IV; metastatic), kidney cancer cells have broken away from the original tumor and have traveled through the lymphatic system or blood to other parts of the body, where they begin growing tumors. The most common site to which kidney cancer spreads is the lungs, but it can spread to the lymph nodes, bones, liver, brain, skin, and other areas in the body. If the cancer has spread to many areas beyond the kidney, it is more difficult to treat.

Patients with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. 

Your health care team may recommend a treatment plan that includes a combination of treatments. Currently, the most effective treatment for metastatic kidney cancer is targeted therapy that slows or prevents tumor growth and blood vessel formation. These drugs have been shown to prolong life when compared with standard treatment. Supportive care will also be important to help relieve symptoms and side effects.

For many patients, a diagnosis of metastatic cancer can be very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Palliative care given toward the end of a person's life is called hospice care. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families.

Clinical Trials

Doctors and scientists are always looking for better ways to treat patients with kidney cancer. To make scientific advances, doctors create research studies involving people, called clinical trials.

Many clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and manage the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating kidney cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with kidney cancer.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. 

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient's options, so that the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. 

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends.

Coping with side effects

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for kidney cancer are described in detail within the Treatment section. Side effects depend on a variety of factors, including the cancer's stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with kidney cancer. 

In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies. 

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care.

After Treatment

After treatment for kidney cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years.

As part of this follow-up care, patients should receive regular blood tests to check kidney function, chest x-rays, CT scans of the abdomen and chest, and other imaging tests to watch for recurrence or metastasis. Patients should have a checkup every three months for the first year, every four months for the second to fifth year, and once a year after that.

Because people treated for kidney cancer often have a single kidney, they will need to be monitored for possible declining kidney function for the rest of their lives. There are few long-term side effects, although some patients may have chronic pain from the surgical scar. Also, people treated for kidney cancer have a slightly higher risk of developing colon cancer and prostate cancer.

People recovering from kidney cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based on your needs, physical abilities, and fitness level.

Latest Research

Doctors are working to learn more about kidney cancer, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Because most kidney cancers do not respond well to traditional chemotherapy, research for kidney cancer focuses on using new and different treatments, immunotherapy, and targeted therapy.

Targeted therapy. Several recently discovered drugs that affect the process of blood vessel development and/or cancer cell growth are being tested as treatments for kidney cancer. The early results from these clinical trials show that these types of drugs may be effective treatments for kidney cancer, and this is an area of rapid scientific change. Tivozanib (AV-951) is still in clinical trials but showing that it may be an effective treatment for kidney cancer. Many targeted therapies are being studied for use as adjuvant therapies, which are treatments given after the main treatment(s) to lower the risk of recurrence and to get rid of any hidden remaining cancer cells. Currently, there are no adjuvant therapies for kidney cancer that have shown significant benefit.

Cancer vaccines. Cancer vaccines are treatments that help a person's immune system fight cancer. Doctors are testing the use of several cancer vaccines to treat kidney cancer and prevent recurrence for people with advanced renal cell carcinoma. One vaccine is made from a person's tumor and given after surgery, while others are made from proteins found on the surface of kidney cancer cells or blood vessel cells found in the tumor.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current kidney cancer treatments in order to improve patients' comfort and quality of life.