Types of Treatment for Kidney Cancer

Executive Summary

Treatment (kidney cancer) recommendations depend upon the size, grade, and type of tumor, metastasis, possible side effects, and patient’s preferences and overall health. While the standard treatment techniques used to treat kidney cancers are surgery and various systemic therapies (chemotherapy, targeted therapy, or immunotherapy) using medication. Active surveillance is beneficial in older adults and people with a tiny renal tumor and other primary medical conditions, such as heart disease, chronic kidney disease, or severe lung disease.

The other standard treatment for kidney cancer also includes surgery (radical nephrectomy, partial nephrectomy, and laparoscopic and robotic surgery), non-surgical treatment (radiofrequency ablation, and cryoablation), therapies using medication (using an intravenous (IV) tube to administer medication into the vein using a needle, and capsule or pill administered orally), systemic therapies (chemotherapy, immunotherapy and targeted therapy), chemotherapy (combination of gemcitabine (Gemzar) with capecitabine (Xeloda) or fluorouracil (5-FU)), targeted therapy (Anti-angiogenesis therapy, Tyrosine kinase inhibitors, mTOR inhibitors, HIF2a inhibitor, and combined therapies), immunotherapy (Interleukin-2 (IL-2), Alpha-interferon, Immune checkpoint inhibitors), and radiation therapy. Palliative care includes medication, nutritional changes, emotional and spiritual support, and other relaxation therapies.

The Healthcare Team

A multidisciplinary approach is necessary to treat any form of kidney cancer. The treatment will include the involvement of different doctors and other healthcare members (called the multidisciplinary team) and will use different treatment strategies. They will care for and evaluate the patient before and throughout the treatment period. The health care team will include the following specialists:

Urologist

A genitourinary tract specialist who specializes in the kidneys, bladder, genitals, prostate, and testicles.

Urologic oncologist

A urologist who specializes in treating urinary tract malignancies.

Medical oncologist

A doctor specialized to treat cancer with medication-based systemic therapy.

Radiation oncologist

This oncologist specializes in radiation therapy. A doctor who specializes in using radiation therapy to treat cancer. This doctor will be a part of the team if radiation therapy is necessary.

Besides these people, cancer care includes a variety of other health care professionals like nurse practitioners, physician assistants, pharmacists, counsellors, dieticians, social workers and many more others. All these people come together to devise a treatment plan as suiting the patient’s cancer condition. The team will design a comprehensive treatment plan by evaluating the patient’s disease condition and overall health. 

Kidney cancer treatment

Kidney cancer treatment focuses on eliminating cancer growth and also to preserve the functions of nearby tissues, organs, and nerves. While planning the treatment strategy, the healthcare team will consider how the treatment will affect the patient’s quality and comfort of life. 

The standard treatment techniques used to treat kidney cancers are surgery and various systemic therapies (chemotherapy, targeted therapy or immunotherapy) using medication ^​1​. The treatment plan will also focus on managing and relieving symptoms, signs and side effects, which forms an essential part of cancer treatment.

Treatment options and plans are designed based on several factors such as the type of kidney cancer, its stage and grade, probable side effects, the patient’s preferences, choices, and overall health condition. Patients should also take time to learn about all the available treatment options and be sure to ask questions and clear doubts about things that are unclear and appears complex. Ask your doctor about the aim of each treatment and what outcome you can expect while receiving the treatment. This is what is called “shared decision making.” Shared decision-making helps the patients to have informed choices regarding treatment. This in fact will help the healthcare team choose and plan a treatment strategy that best fits your aims and expectations.

Active Surveillance

The doctor may advise that the tumor be under close observation with regular diagnostic testing and clinic visits. “Active surveillance” is the term for this. Active surveillance is beneficial in older adults and people with a tiny renal tumor and other major medical conditions, such as heart disease, chronic kidney disease, or severe lung disease. Even if cancer has spread to other parts of the body, active surveillance may be necessary for some people with kidney cancer if they are otherwise healthy and have little or no symptoms. Systemic therapy can also help if the condition is progressing.

Active monitoring is not the same as “watchful waiting for kidney cancer.” Regular appointments to discuss symptoms are necessary under watchful waiting, but patients do not engage in routine diagnostic testing such as biopsies or imaging scans. The doctor merely keeps an eye out for signs and symptoms. A new treatment plan might also be necessary in case of signs and symptoms.

Following are some popular treatment strategies to treat kidney cancers:

SURGERY

Surgery is a procedure where the tumor and some surrounding healthy tissues are removed via an operation. It is one of the best treatments for treating and destroying kidney cancers. Surgery to remove the tumor may be the only treatment necessary if the cancer has not progressed or metastasized beyond the kidneys. During surgery, part or all of the kidney and adjacent tissue and lymph nodes may be removed to eliminate the tumor. There are different types of surgical procedures for treating kidney cancers such as ^​2​:

Radical nephrectomy

a surgical procedure that removes the tumor, the entire kidney, and the surrounding tissue. Radical nephrectomy and lymph node dissection are necessary if the disease has spread to neighboring tissue and lymph nodes. The cancer-affected lymph nodes are removed during a lymph node dissection. If cancer has spread to the adrenal gland or surrounding blood vessels, the surgeon will remove the adrenal gland and sections of the blood arteries during adrenalectomy. Radical nephrectomy is necessary when there is no good tissue left after the tumor. The renal tumor may develop directly inside the renal vein and enter the vena cava on its route to the heart. Complex cardiovascular surgical techniques will also be necessary if this occurs.

Partial nephrectomy

The tumor is surgically removed in partial nephrectomy. This sort of surgery helps to preserve kidney function and to reduce the risk of developing a chronic renal disease. Research has shown that partial nephrectomy is beneficial for treating T1 tumors whenever surgery is not possible. However, newer surgical techniques that use a smaller surgical incision or cut cause less adverse effects and better recovery.

Laparoscopic and Robotic surgery

These are minimally invasive surgery. During laparoscopic surgery, the surgeon makes multiple minor cuts in the belly instead of a single bigger cut as in traditional surgery. The surgeon then uses telescopic tools to entirely remove the kidney or perform a partial nephrectomy through these microscopic keyhole wounds. The surgeon may also employ robotic devices to execute the procedure in some cases. This procedure may take longer, but it is likely to be less painful. The use of laparoscopic and robotic techniques necessitates specialized training. It is crucial to talk to your surgical team about these procedures’ potential benefits and hazards and ensure that they’ve experienced doing the procedure.

Patients must enquire about the type of surgery necessary to remove the cancer growth and the associated side effects to their healthcare team.

NON-SURGICAL TREATMENTS

Surgery is not always necessary because of the tumor’s features or the patient’s overall health. To determine if these treatments are appropriate and safe for them, each patient should fully discuss their diagnosis and risk factors with their doctor. Following are some other methods to treat kidney tumors:

• Radiofrequency ablation: The use of a needle put into the tumor to eliminate the malignancy with an electrical current which is the radiofrequency ablation (RFA) ^​3​. An interventional radiologist or urologist performs the procedure. The patient is under sedation and given a local anaesthetic to numb the area. RFA was previously for patients who were too weak to undergo surgery. The majority of these patients are now under active surveillance.
• Cryoablation: The freezing of cancer cells with a metal probe inserted through a small incision is known as cryoablation, sometimes known as cryotherapy or cryosurgery. The malignant tissue is probed with a metal probe. A CT scan and ultrasonography guide the probe. An interventional radiologist performs the treatment, which requires general anaesthesia for many hours. Some surgeons use this procedure in conjunction with laparoscopy to treat the tumour, but there isn’t any long-term study to back it up.

Therapies Using Medications

Treatments using medications are helps to eliminate cancer cells. Such therapies are called systemic therapy. Systemic therapy refers to medication or drugs to eliminate cancer cells. These drugs or medicines are administered through the bloodstream to reach tumour growths or cells throughout the body. Medicated therapies can also be administered to the patient’s body locally, where the medication or drug is applied directly on the tumour or is kept in a single part of the body.

A medical oncologist usually prescribes such therapies. Systemic therapies are commonly in two ways:

• Using an intravenous (IV) tube to administer medication into the vein using a needle.
• A capsule or pill that is swallowed or administered orally.

The systemic therapies used to treat kidney cancers are Chemotherapy, Immunotherapy, and Targeted Therapy. A patient may receive one of these, or sometimes a combination of both administered simultaneously. Systemic therapies can also be a part of the overall treatment plan, including surgery or radiation.

Studies

Many studies focus on developing efficient medications that can help treat and cure cancer. Patients must also talk with their doctor about the prescribed medicines and learn and understand more about them. Ask them questions regarding the purpose, possible side effects of the drugs, and their possible interactions with other treatments and medications. One should also let their doctor know about any additional treatment or medicines they are taking well before cancer treatment. This is because certain drugs and herbs can interact with cancer medications and can cause complications.

Chemotherapy

Chemotherapy or chemo procedure refers to drugs or medications to eliminate cancer cells. These drugs operate by preventing the cancer cells from growing, dividing and generating more cells. A chemo regimen generally consists of several cycles given over a period of time. A patient may receive a single type of drug or a combination of different medications, all given simultaneously.

Chemotherapy is effective in treating various cancers, but most cases of kidney cancer are resistant to it ^​4​. Researchers are still looking at new drugs and pharmacological combinations. The combination of gemcitabine (Gemzar) with capecitabine (Xeloda) or fluorouracil (5-FU) can temporarily reduce a tumor in some people.

It’s vital to remember that transitional cell carcinoma, also known as urothelial carcinoma, and Wilms tumour are far more likely to respond to chemo treatment.

Chemotherapy can cause side effects, and these depend on the dose of medication used and the individual’s overall health. But common side effects include nausea and vomiting, hair loss, fatigue, loss of appetite, risk of infection, and diarrhoea. These side effects are likely to vanish after the treatment is over.

Targeted therapy

Targeted therapy refers to a systemic treatment that targets specific genes, proteins of the cancer cells and the surrounding tissue that contributes to tumour growth and proliferation. This therapy shuns cancer’s development and metastatic capability by causing very little damage to the surrounding healthy cells. 

The targets of each tumour differ. The doctor might also run various tests or scans to identify the tumour’s proteins, genes, and other characteristic features to choose the suitable treatment option. This helps the doctor to implement the most effective treatment. Many types of research are happening in this field, too, to devise better target therapy options.

Targeted therapies used to treat kidney cancer is as follows ^​5​:

Anti-angiogenesis therapy

Angiogenesis is the process of forming new blood vessels, and this type of treatment aims to inhibit it. Most clear cell kidney tumors contain VHL gene mutations, which cause the malignancy to produce excessive amounts of a protein called vascular endothelial growth factor (VEGF). VEGF is a protein that regulates the creation of new blood vessels and certain medicines hamper this. Anti-angiogenesis therapies aim to “starve” a tumor of nutrients given by blood vessels, which are necessary for it to develop and spread. Small chemical inhibitors of the VEGF receptors (VEGFR) or antibodies directed against these receptors are two strategies to block VEGF.

Bevacizumab (Avastin)

For persons with metastatic renal cell carcinoma, an antibody bevacizumab (Avastin) suppresses tumour growth. Bevacizumab, in combination with interferon, inhibits tumour growth and spread. The U.S. Food and Drug Administration (FDA) has approved two identical medications for the treatment of metastatic kidney cancer: bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev). These are referred to as biosimilars. And they work in a similar way to the original bevacizumab antibody.

Tyrosine kinase inhibitors

Tyrosine kinase inhibitors are another technique to block VEGF (TKIs). TKIs that block VEGF receptors include axitinib (Inlyta), cabozantinib (Cabometyx), pazopanib (Votrient), lenvatinib (Lenvima), sorafenib (Nexavar), sunitinib (Sutent), and tivozanib (Fotivda). They can also treat kidney carcinoma with clear cells. TKIs can cause diarrhoea, elevated blood pressure, and pain and sensitivity in the hands and feet, among other things. Pazopanib, sunitinib, and cabozantinib are three of the authorized medications frequently utilized as first-line treatments. Axitinib or cabozantinib along with immunotherapy can be a first-line treatment. They may be recommended if axitinib, cabozantinib, lanvatinib, and tivozanib have not been utilized after first-line treatment.

mTOR inhibitors

Everolimus (Afinitor) and temsirolimus (Torisel) are medications that target mTOR, a protein that aids in the growth of kidney cancer cells. These medications slows down kidney cancer progression according to the various studies.

HIF2a inhibitor

Belzutifan (Welireg) is a medication that inhibits the growth of blood vessels and cancer cells by inhibiting the protein hypoxia-inducible factor-2 alpha (HIF2a). Belzutifan is a drug that can treat von Hippel-Lindau syndrome patients with renal cell carcinoma.

Combined therapies

The FDA approved two combination therapies for advanced renal cell carcinoma for the first time in 2019. Axitinib and pembrolizumab (Keytruda), an immune checkpoint inhibitor, make the first combination. Axitinib and avelumab (Bavencio), an immune checkpoint inhibitor, are used in the second combination. The Axitinib is an angiogenesis inhibitor. Both pembrolizumab and avelumab engage the immune system to fight cancer cells by targeting the PD-1 pathway.

The FDA approved two more combination treatments for advanced renal cell carcinoma in 2021: cabozantinib (an anti-angiogenesis therapy) with nivolumab (an immune checkpoint inhibitor blocking the PD-1 pathway) and lenvatinib (also an anti-angiogenesis therapy) with pembrolizumab (an immune checkpoint inhibitor blocking the PD-1 pathway). People who take this treatment will not be screened for PD-L1. It is because these treatment combinations operate independently of whether the tumour expresses the PD-L1 protein. While these medicines have been approved based on better results than sunitinib, none of the combinations has been directly compared. As a result, based on each patient’s specific situation, the doctor will select the most appropriate treatment approach.

Talk with your healthcare team regarding the possible side effects of such therapies and the ways of prevention and management.

Immunotherapy

Immunotherapy or the biologic therapy, is a medicated treatment focuses on improving the body’s natural defences to fight and destroy cancer growth. This therapy uses materials made either naturally by the body or in a lab to improve, target or restore the functions of the immune system.

Interleukin-2 (IL-2)

is a kind of interleuk (IL-2, Proleukin). IL-2 is immunotherapy to treat kidney cancer in its latter stages. It’s a protein produced by white blood cells called a cytokine. It plays a role in immune system function, including tumour cell killing.

Low blood pressure, extra fluid in the lungs, renal damage, heart attack, hemorrhage, chills, and fever are serious side effects of high-dose IL-2. Some symptoms, however, may be reversible. Only clinics with experience treating kidney cancer with high-dose IL-2 should recommend it. The high-dose IL-2. can help to cure a tiny percentage of persons with metastatic kidney cancer. Low-dose IL-2 has fewer adverse effects, although it is less effective.

Alpha-interferon

Alpha-interferon helps 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, alpha-interferon has been shown to lengthen lives compared with an older treatment called megestrol acetate (Megace).

Immune checkpoint inhibitors

• Immune checkpoint inhibitors, a kind of immunotherapy, are under research in kidney cancer. The FDA has authorized the following immune checkpoint inhibitor therapies for kidney cancer:
• For specific individuals with advanced renal cell carcinoma who have not previously been treated, nivolumab (Opdivo) and ipilimumab (Yervoy) are used.
• As a first-line treatment for advanced renal cell carcinoma, nivolumab combined with cabozantinib.
• The combination of avelumab (Bavencio) with axitinib as a first-line treatment for advanced renal cell carcinoma.
• People with advanced renal cell carcinoma should receive pembrolizumab (Keytruda) plus axitinib as a first-line treatment.
• For persons with advanced renal cell carcinoma, pembrolizumab plus lenvatinib is used as a first-line treatment.
• Pembrolizumab alone can cause a high risk of recurrence after nephrectomy or surgical excision of metastatic sites.

Immunotherapy drug combinations

Extensive clinical trials comparing the immunotherapy combinations to sunitinib in persons with advanced or metastatic kidney cancer led to advanced renal cell carcinoma approvals. Additional studies had previously shown that nivolumab, administered as a single dose through the vein every two weeks, helped those who had previously undergone anti-angiogenesis treatments live longer than patients treated with the targeted therapy everolimus. Pembrolizumab was approved after surgery after a large clinical trial indicated an improvement in time to recurrence for persons who had surgery for the original kidney tumour or all sites of distant metastasis. Several clinical trials involving immune checkpoint inhibitors for the treatment of kidney cancer are currently underway.

Different types of immunotherapies can cause various side effects. Common side effects of the procedure include flu-like symptoms, skin reactions, weight changes and diarrhoea. Talk with your healthcare team or doctor regarding the possible side effects of the immunotherapy procedure recommended for you. 

RADIATION THERAPY

Radiation therapy is the use of high-energy x-rays or other particles to eliminate cancer cells. A radiation oncologist is a doctor who specializes in treating cancer patients with radiation therapy.

As a first-line treatment for kidney cancer, radiation therapy is ineffective. It is rarely used alone to treat kidney cancer because of the harm it inflicts to the healthy kidney. Only if a patient is unable to have surgery is radiation therapy utilized. Even then, it is usually only in places where cancer has progressed rather than on the underlying kidney tumor. When cancer has spread, radiation therapy is a usual procedure. This is to aid the symptoms such as bone pain and brain swelling.

Physical, emotional, and social effects of kidney cancer

Cancer can cause many physical, emotional, and social effects. Cancer care does not end with active treatment. Post-treatment care is as critical as active treatment. Palliative or supportive care focus on managing and relieving symptoms and side effects associated with cancer treatment. Along with an active treatment strategy, it can help in improving the treatment efficiency by slowing the cancer growth or destroying it.

Palliative care focuses on improving a patient’s condition by helping them to manage and relieve symptoms. The care extends support not just to the patients but also to their loved ones. It also focuses on the non-medical needs of cancer patients, like managing finances. Palliative care is independent of the age, cancer stage or type of patient. Palliative care works best when it begins right after a cancer diagnosis. This helps prevent the cancer condition and its symptoms and side effects from aggravating. Palliative focuses on improving the comfort and quality of a patient’s life. Palliative care enhances the effectiveness of active treatment. Sometimes a patient may receive chemotherapy, surgery or radiation therapy as palliative care.  

Patients should talk with their health care team about the aim of each treatment option, about the probable side effects and the available palliative care options before the active treatment begins.

The health care team will enquire about your medical history, symptoms and side effects during treatment. Be sure to communicate whatever you are feeling to the doctor. This helps them treat any symptoms or side effects that you are experiencing with ease. This will eventually help prevent your condition from becoming worse. 

Metastasis of kidney cancer

Metastatic cancer refers to cancer or tumour that spreads from its origin to different body parts. If you are experiencing any signs or symptoms related to cancer metastasis, communicate it with your doctor. The doctor or the health care team will develop an active treatment plan to cure this condition. One can also go for clinical trial options. 

Metastasis can occur even after active treatment and removal of the cancer growth. Hence it can be stressful for the patient and their loved ones to bear the diagnosis. So, patients and their loved ones should have active communication with the doctor, nurses, social workers, or counselors regarding how they are feeling. Patients can also talk with other cancer survivors or join a support group.

Remission and the chance of Cancer Recurrence

Remission refers to a stage where there are no signs or symptoms of cancer in the body. The condition can be called NED or “no evidence of disease” in the body. Remission can be permanent or temporary. Cancer patients in remission might be anxious about a probable cancer recurrence. Patients must continue tests, scans, and physical examinations even after successful treatment to look for recurrence. Talk with your doctor about the chance of the cancer condition recurring back in your body. If cancer recurs in the same place as before, it is a local recurrence, and if it happens nearby the origin point, it is a regional recurrence. If it recurs in some distant place in the body, it is a distant recurrence.

Care and Concern

Cancer recovery may not be successful at times. The disease condition might be advanced or terminal. Any stage of cancer can be stressful for people. A diagnosis that states an advanced, aggressive tumor can cause even more stress and make people hopeless and uncertain about their lives. Patients should have open, honest communications with their doctor or health care team about their concerns, feelings, and preferences. Health care team members will support the patients and their caregivers. They will focus on improving the comfort and quality of the patient’s life by providing them physical, mental, and financial support.

People diagnosed with advanced cancer and the expected chance of survival is for less than six months can consider hospice care. Hospice care focuses on providing the best possible quality care for patients whose survival chance is low. Patients and their families can talk to the health care team about the available hospice options, including a unique hospice centre, hospice care at home or any other health care location. People can also avail nursing care options.

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