Treatment for advanced kidney cancer

Tuesday 1 November, 2016

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On this page: Active surveillance | Surgery | Targeted therapy | Immunotherapy | Radiotherapy | Palliative treatment | Key points


When kidney cancer has spread outside the kidney and to other parts of the body, the usual goal of treatment is to control the cancer, to slow down its spread and to manage any symptoms.

Combinations of different treatments may be recommended by various members of your treatment team, including urologists, medical oncologists and radiation oncologists. The best sequence or combination of treatments depends on many factors, so the right treatment for each patient is different.

Watching and waiting (active surveillance) may be an option for some people. The main medical treatment to help control advanced kidney cancer is targeted therapy. Other possible treatments include immunotherapy and radiotherapy. Surgery to remove the kidney affected with cancer might also be recommended. Chemotherapy isn’t usually used for treating kidney cancer – other treatments such as targeted therapy or immunotherapy appear to work better.

Active surveillance

In some cases when kidney cancer has spread, the cancer grows so slowly that it won’t cause any problems for a very long time. Because of this, especially if the advanced kidney cancer has been discovered unexpectedly, your doctor may suggest observing the cancer at regular intervals, 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.

Surgery

Surgery to remove kidney cancer when the cancer has spread is called 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).

In some circumstances, surgery may improve survival, especially when given before targeted therapy (see below). It can also reduce current symptoms or the risk of future symptoms from the cancer in the kidney. Generally, surgery is not recommended if you are unwell or if the cancer has spread to many places in the body.

Targeted therapy

If you have advanced kidney cancer that is growing quickly or causing symptoms, your doctor is likely to suggest targeted therapy. This works in a different way to chemotherapy. While chemotherapy affects all rapidly dividing cells and works by killing cancerous cells (cytotoxic), targeted therapy targets specific molecules within cells and often works by blocking cell growth (cytostatic).

Different types of targeted therapy drugs are used for advanced kidney cancer (see below). Most are in the form of tablets that you take at home.

Cancers often become resistant to particular targeted therapy drugs. If this happens, your doctor will usually suggest trying another targeted therapy drug or another treatment.

Types of targeted therapy for kidney cancer

The main types of targeted therapy used for advanced kidney cancer are listed below. In Australia, some of these are available on the Pharmaceutical Benefits Scheme (PBS) as long as certain criteria are met. This means that the government covers most of the cost. Medicines or treatments that are not on the PBS are usually very expensive unless given as part of a clinical trial.

Tyrosine kinase inhibitors (TKIs)
  • Tyrosine kinase inhibitors (TKIs) block the function of a group of enzymes called tyrosine kinases, in particular VEGFR (vascular endothelial growth factor receptor).
  • To spread into surrounding tissue, a tumour has to grow its own blood vessels. This process is called angiogenesis. VEGFR TKIs are angiogenesis inhibitors, which means they block the growth signals to blood vessel cells. This cuts off blood supply to the cancer and stops the cancer growing.
  • The main VEGFR TKIs currently used for kidney cancer in Australia are sunitinib, pazopanib, sorafenib and axitinib. Others, including lenvatinib and cabozantanib, have been shown to be beneficial in clinical trials, but are not yet available in Australia.
Mammalian target of rapamycin (mTOR) inhibitors
  • Mammalian target of rapamycin (mTOR) is an enzyme that tells cancer cells to grow and spread; mTOR inhibitors block this enzyme.
  • Everolimus is an mTOR inhibitor that is on the PBS in Australia, but it can be used only if kidney cancer has progressed after taking a VEGFR TKI.
Side effects of targeted therapy

Targeted therapy drugs minimise harm to healthy cells, but they can still have side effects. These vary depending on the drug used, but may include fatigue, mouth ulcers, changes in appetite, fevers, allergic reactions, rashes, diarrhoea, blood-clotting issues and blood pressure changes.

Immunotherapy

Immunotherapy is treatment that works by enhancing the body’s own immune system, in the hope that it will then attack the cancer. Some older immune therapies like interferon alpha and interleukin-2 were successful in some kidney cancer patients, but were very toxic and so are now rarely used.

A new family of immunotherapy drugs work by permitting the immune system to bypass ‘checkpoints’ set up by the cancer that block the immune system. Several of these checkpoint immunotherapy drugs are already approved for the treatment of other cancers like melanoma, lung cancer and bladder cancer. Nivolumab is a checkpoint immunotherapy drug that has been shown to be effective in people with advanced kidney cancer previously treated with a VEGFR TKI. However, it is not currently reimbursed for kidney cancer in Australia (as of 2016).

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 in combination with existing kidney cancer drugs like TKIs.

Radiotherapy

Radiotherapy uses radiation, such as x-rays, gamma rays, electron beams or protons, to kill or damage cancer cells. It is also known as radiation therapy. Radiotherapy might be used in advanced kidney cancer to shrink a tumour and relieve symptoms (palliative treatment, see below).

If you have radiotherapy, you will lie on a treatment table under a machine called a linear accelerator. The treatment itself takes only a few minutes, but each session may last 10–20 minutes because of the time it takes to set up the equipment. You will be able to go home once the session is over.

The total number of treatments and their duration depend on your situation. You might have some side effects, such as fatigue, nausea, appetite loss, diarrhoea, tiredness and skin irritation.

Talk to your doctor and nurses about any side effects you experience so you can get advice about managing them. You can also read Understanding Radiotherapy or call Cancer Council 13 11 20 for more information.

Palliative treatment

In some cases of advanced kidney cancer, the medical team may talk to you about palliative treatment. Palliative treatment helps to improve quality of life by alleviating symptoms of cancer. It can be used at any stage of advanced cancer.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include radiotherapy, arterial embolisation (a procedure that blocks the blood supply to the kidney and the tumour inside it), or drug therapies.

Palliative treatment is one aspect of palliative care, in which a team of health professionals aim to meet your physical, emotional, practical and spiritual needs.

For more information, you can read Understanding Palliative Care and Living with Advanced Cancer. You may also be interested in Overcoming Cancer Pain, or ordering free relaxation and meditation CDs. Call 13 11 20 to request free copies of these resources.

Key points

  • Advanced cancer means the cancer has spread from where it started to another part of the body, or it has come back some time after you were first treated.
  • In some people, the cancer may be growing so slowly that the doctor suggests active surveillance. This means checking the growth of the cancer with regular scans.
  • If the primary kidney cancer is the largest site of disease and the cancer has not spread very much, the primary kidney cancer may be removed (cytoreductive nephrectomy).
  • In some cases, surgery can remove some or all of the cancer that has spread (metastasectomy).
  • Targeted therapy drugs target specific molecules within cells and often work by blocking cell growth.
  • The most commonly used targeted therapies for advanced kidney cancer are VEGFR tyrosine kinase inhibitors (TKIs) and mTOR inhibitors.
  • Immunotherapy uses drugs that encourage the immune system to fight the cancer cells. These checkpoint immunotherapy drugs are the focus of many clinical trials.
  • Radiotherapy may be used to shrink a tumour that is causing symptoms in people with advanced kidney cancer.
  • Some people might be offered palliative treatment, such as radiotherapy and arterial embolisation. Palliative treatment is given to ease the symptoms of the cancer.
  • All of the treatments can cause side effects, such as pain, fatigue or diarrhoea. Talk to your doctor about how to manage any side effects.

Reviewed by: Dr Craig Gedye, Medical Oncologist, Calvary Mater Hospital, Newcastle, and Senior Conjoint Lecturer, School of Biomedical Sciences and Pharmacy, The University of Newcastle, NSW; Gregory Bock, Urology Cancer Nurse Coordinator, WA Cancer and Palliative Care Network, WA; A/Prof Declan Murphy, Urologist, Chair of Uro-Oncology and Director of Robotic Surgery, Peter MacCallum Cancer Centre, VIC; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA, WA; Jodie Turpin, Consumer.

Updated: 01 Nov, 2016