More than 50,000 new cases of kidney cancer are diagnosed in the United States each year. Advances in treatment for kidney cancer have given many cancer patients an improved outlook.
If you have been diagnosed with kidney cancer, you probably have many questions about your disease, how it is likely to be treated, and what happens when treatment is completed. The treatment summaries, which are based on the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines™), will help you understand the best available treatments for kidney cancer. Talk to your doctors about these therapies so that together you can decide on a cancer treatment plan that is right for you.
Background
The kidneys are a pair of organs on either side of your spine a bit above your waist; they are responsible for clearing waste products out of your blood. The kidneys are most efficient when both are in good working order, but a person can live with just one kidney, even if that one is not functioning with 100% efficiency. The kidneys are made up of tiny tubes (ducts) that filter the blood, remove waste, and make urine. Kidney cancer most often develops in these ducts.
Kidney cancer is divided into two large groups, each of which represents different types of cells and has different treatment requirements. Separate treatment summaries are available for each of these types (click on the one of interest to you):
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Renal cell cancer: About 90% of kidney cancers are renal cell cancers. This treatment summary concerns renal cell cancer.
- Transitional cell cancer of the renal pelvis: A less common type of kidney cancer is transitional cell cancer, which originates from cells lining the kidney. It will be discussed in the bladder cancer summary, available in late 2009.
Renal cell cancer is further classified by the type of normal cell that has become cancerous. Knowing the subtype is important because it determines how aggressive the cancer is and how easily it can be treated.
Clear cell is the most common subtype and accounts for about 85% of all cases. All other subtypes (such as papillary or sarcomatoid) are less common, accounting for 15% of all cases, and are referred to as non-clear cell.
This summary describes the tests and treatments for renal cell carcinoma only. Treatment of transitional cell cancer is discussed under bladder cancer.
Smoking, obesity, and overuse of over-the-counter pain medications are some risk factors for kidney cancer, but people with no risk factors also get this type of cancer.
Diagnosis
Many kidney cancers are found accidentally when a patient has a chest x-ray or CT scan for another reason. Some patients have blood in their urine or pain in their side that does not go away. Others have unexplained weight loss or fatigue. If kidney cancer is suspected, your doctor will take a complete medical history and perform a physical exam. Your doctor will arrange for tests, including a urinalysis to look for blood or cancer cells in your urine and imaging tests such as ultrasound or CT to look for a mass on your kidney.
Most patients with kidney cancer do not require a biopsy. If imaging tests (CT and ultrasound) show the tumor is confined to the kidney, then surgery is performed to remove the entire tumor. The tumor mass that has been surgically removed is then sent to a pathologist to determine whether the cancer started in the kidney; the type and subtype of kidney cancer and whether cancer has spread outside the kidney to the lymph nodes and other organs. If tumor has spread outside the kidney, biopsy may be performed in sites where the tumor has spread outside the kidney.
If cancer is confirmed, your doctor will recommend additional tests to determine whether the cancer has spread and, if so, to which part or parts of your body. These tests will probably include blood tests, chest imaging (x-ray or CT) if not already done, and MRI of the brain. PET scans are rarely used for kidney cancer.
Staging
A formal system called staging is used to identify how localized or widespread your cancer is. Stages range from I (most localized) to IV (spread to distant organs in your body). Staging is an important part of developing the best treatment plan for you. For a more detailed discussion of staging, see the Cancer Staging Guide.
Kidney cancer is divided into stages that describe whether the cancer is confined to the kidney (early stage) or has spread to other organs (late stage). Doctors determine the stage using the sample of tissue obtained from your kidney and/or lymph nodes and from imaging studies that show whether cancer has (or has not) spread to other organs. People with stage IV kidney cancer have tumors that have spread to other organs regardless of the size of the tumor or whether cancer is found in the lymph nodes.
In general, the lower the stage of disease, the better the chance that your cancer can be cured. The higher the stage, the less likely it is that your cancer can be cured; however, newer treatments have made it possible for people with late stage disease to live longer, high-quality lives. Staging is used both to help your doctors make treatment decisions and to provide you and your doctors with information about what typically happens to patients with cancers most like yours.
Treatment
No single kidney cancer treatment is right for everyone. You can make the best decision by discussing the benefits, risks, and possible side effects of each treatment described below with your physician.
The goal of treatment for patients with advanced disease is to reduce the amount of cancer, slow its growth, and minimize symptoms associated with the disease and its treatment to let them live a longer, high-quality life.
Treatment for advanced kidney cancer is one of the most rapidly changing areas of oncology. In the past 4 years, several new drugs have been approved by the federal Food and Drug Administration (FDA) to treat kidney cancer. These have changed the outlook for people with advanced kidney cancer significantly.
Typically, patients with advanced kidney cancer undergo systemic therapy (the use of cancer-killing drugs—chemotherapy or biologic therapy or targeted therapy—that travel throughout the body) to kill or slow the growth of cancer cells or to disrupt processes that encourage the growth of cancer cells. These treatments may be used together or separately.
Depending on your situation, you may also receive local therapy, such as surgery to remove the tumor in the kidney or possibly to remove an isolated tumor in another place in your body.
The treatments that are right for you will be influenced by your general health. One factor that is considered is called performance status. This refers to how many of your normal activities you are able to perform. If you can do most of your regular activities, you probably will be able to stand more intensive treatment. If you are bedridden, you will need milder treatments. If the restrictions on your activities are from the cancer and not some other health problem, these milder treatments may help you become well enough to take the more intensive treatments later.
Your doctor should provide you with a written care plan explaining what treatments you will have, when they will occur, how often (if you will have systemic therapy), and what side effects you may experience. Some side effects can be anticipated, and you can undergo treatment to reduce their severity. You will be asked to sign an informed consent document indicating that you have been told about your treatment and what to expect. It is very important that you ask your doctor or nurse every question you have. Cancer and its treatment are complicated, and most patients have questions.
Surgery
While surgery for advanced kidney cancer or stage IV cancer that has spread (metastasized) to other organs usually does not cure the disease, surgery is nonetheless an important part of the treatment plan in several situations:
- If there is only one metastatic tumor (a tumor somewhere besides in the kidney) and the original kidney tumor can be completely removed, surgery may be recommended to remove the entire kidney as well as the metastatic tumor. If you have this surgery, you will be monitored by your doctor in much the same way as a patient with early stage disease, with no further active treatment unless the cancer recurs (comes back). (See Kidney Cancer - Early Stage for more information.)
- If the cancer has spread to more than one organ, a cytoreductive nephrectomy may be recommended before you receive systemic treatment. In this surgery, the kidney and the cancer in it will be removed to reduce the amount of cancer in your body and thus improve the effectiveness of systemic treatment. This technique is most appropriate for people who are in good health aside from their cancer and are able to go about their daily lives normally and who have tumors that have spread only to the lungs.
Clinical trials of cytoreductive nephrectomy followed by biologic therapy were performed some years ago with interferon, the most widely used biologic drug at the time. More recently, newer targeted therapies that are more effective than interferon have become available. Your doctor can determine whether you are a candidate for surgery followed by one of these targeted therapies.
Systemic Therapy
Most patients with advanced disease will have some form of systemic therapy: targeted therapy, biologic therapy (which uses substances that occur naturally in your body to fight the cancer), or chemotherapy (which uses drugs to kill or slow the growth of tumor cells).
Targeted Therapy
New treatments, called targeted therapies, are directed toward certain processes occurring in tumor cells and help shrink the tumor size and slow tumor growth. Sunitinib and sorafenib are tyrosine kinase inhibitors. They stop cancer cells from growing and block the development of blood vessels that supply nutrients to the tumor. These drugs are taken by mouth. Sunitinib and sorafenib have been shown to be effective for patients with advanced clear cell carcinoma.
Most clinical trials testing sunitinib and sorafenib for advanced kidney cancer have been performed in people with the most common subtype of renal cell cancer, clear cell. Therefore, the benefits of these treatments are best understood in that subtype.
However, these targeted therapies are also recommended for people with non-clear cell kidney cancer. People with non-clear cell kidney cancer may wish to participate in ongoing clinical trials because treatement under study may offer benefits over currently available treatments, and to help advance treatment for this type of kidney cancer.
Another new drug, bevacizumab, is thought to help decrease the production of new blood vessels to the tumor, helping to "starve" the tumor of nutrients needed to grow. It is given as an intravenous infusion. Bevacizumab is now approved by the FDA in combination with the biologic therapy interferon for clear cell subtypes of kidney cancer.
Temsirolimus is a drug that affects the cancer cell survival and slows cancer growth. This drug is given intravenously. It was tested and found to be effective in patients with kidney cancer with either the clear cell or the non-clear cell subtype, whose disease had spread to 2 or more sites, and who were able care for themselves but were not well enough to carry on their normal activities or go to work.
Everolimus is another drug approved by the FDA for patients with kidney cancer with advanced disease. Although it works like temsirolimus, it is a tablet and taken orally. Currently, everolimus is recommended for patients whose disease progresses after treatment with either sunitinib or sorafenib.
Biologic Therapy
Biologic therapies are treatments that help your body’s own immune system fight cancer. Until recently, these were the only treatments available for advanced kidney cancer. Interleukin 2 is one type of biologic therapy used in kidney cancer. For some patients, high-dose interleukin-2 has been shown to eliminate all detectable disease; however, it can have severe side effects and is therefore only appropriate for patients who are very healthy other than their cancer
Interferon, once a mainstay of treatment for advanced kidney cancer, is now recommended only for use with bevacizumab or alone after other treatments have failed.
Chemotherapy
Chemotherapy is a single drug or combination of drugs (called a regimen) used to kill or slow the growth of cancer cells throughout the body. Chemotherapy is sometimes used in kidney cancer, especially in patients with the non-clear cell subtype if other treatments have proven to be ineffective. However, its use is controversial.
Chemotherapy may be given by injection into a vein or taken orally, depending on the drug. It is usually given in cycles over a period of months. See Guide to Chemotherapy for more information.
Supportive Care
For many patients with advanced stage kidney cancer, an important part of treatment is supportive care, sometimes called palliative care. The goal of supportive care is to improve the quality of life for cancer patients by preventing or treating cancer symptoms and the side effects of treatment. Examples of supportive care for patients with kidney cancer include surgery for solitary brain metastasis or spinal cord compression or radiation therapy with drugs called bisphosphonates to help treat painful bone metastases.
While receiving supportive care, you will visit your doctor at regular intervals, and you may need to undergo x-rays and blood tests or other assessments. The timing of these visits and test will depend on your individual needs.
Clinical Trials
New therapies and combinations of therapies are enabling people with cancer to live longer, better-quality lives than ever before. You may want to find out whether you are eligible to participate in a clinical trial, in which new and experimental therapies are compared with standard treatments. More information on clinical trials is available in the Guide to Clinical Trials and Demystifying Common Clinical Trial Myths.
Prognosis
In determining a prognosis—the likely course or outcome of a disease and its treatment—a doctor may look at kidney cancer survival statistics taken from studies of large groups of patients. However, these statistics:
- Are estimates only
- Can vary widely with each cancer stage
- Are sometimes based on older data that do not reflect recent advances in early detection and treatment
- Cannot be used to precisely predict your survival
Your individual prognosis will be affected by many factors, including:
- Your age
- Your overall health
- The stage of your cancer
- Your response to the treatments being used