Kidney cancer


Treatment for advanced kidney cancer

Tuesday 1 January, 2019

When kidney cancer has spread outside the kidney 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.

A combination of different treatments may be recommended by your treatment team. The best combination of treatments depends on many factors, so the right approach for each person will vary:

  • Watching and waiting (active surveillance) may be an option for some people.
  • Systemic treatment with targeted therapy or immunotherapy drugs is the main medical treatment to help control advanced kidney cancer. Since the development of these more effective treatments, chemotherapy is rarely used.
  • Radiation therapy may be suitable for some people.
  • Surgery to remove the affected kidney might be recommended in certain circumstances, for example, if the cancer is causing symptoms.

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).

Recent studies suggest that treatment with targeted therapy alone is as effective as surgery followed by targeted therapy, and many people with advanced kidney cancer are now managed with targeted therapy alone (see below). Cytoreductive nephrectomy may still be offered in certain circumstances, such as when the kidney cancer is causing symptoms, or in people who have very little cancer spread outside 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

This is a type of drug treatment that attacks specific features of cancer cells to stop the cancer growing and spreading. The type of targeted therapy most frequently used to treat advanced kidney cancer is a group of drugs called small molecule inhibitors. These drugs can get inside cancer cells and block certain enzymes and proteins that tell cancer cells to grow, multiply and spread.

Most small molecule inhibitors are in the form of tablets that you take at home. They are commonly given in repeating cycles, with rest periods in between. Some may be taken daily for many months or even years. How long you take the drugs will depend on the aim of the treatment, how the cancer responds, and the side effects you have.

The two main types of small molecule inhibitors used for advanced kidney cancer in Australia are:

  • Tyrosine kinase inhibitors (TKIs) – these 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. The main TKIs used are sunitinib, pazopanib, cabozantinib, sorafenib and axitinib.
  • mTOR inhibitors – these drugs block mammalian target of rapamycin (mTOR), an enzyme that tells cancer cells to grow and spread. Everolimus is an mTOR inhibitor approved for use for some types of advanced kidney cancer that have not responded to TKIs.

The Pharmaceutical Benefits Scheme (PBS) subsidises the cost of these targeted therapy 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.

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. See Understanding Targeted Therapy or listen to our podcast episode "New Cancer Treatments".

Side effects of targeted therapy

Ask your doctor what side effects you may experience and how long your treatment will last. Targeted therapy drugs minimise harm to healthy cells, but can still cause side effects. These vary depending on the drug used and how your body responds, but may include fatigue, mouth ulcers, changes in appetite, fevers, allergic reactions, skin rashes, diarrhoea, blood-clotting issues and blood pressure changes.

It's important to discuss any side effects of targeted therapy or immunotherapy drugs with your medical team as soon as they appear, so they can be managed appropriately. Early treatment is likely to shorten the length of time a side effect lasts.

Immunotherapy

Immunotherapy is a type of cancer drug treatment that focuses on using the body's own immune system to fight cancer. Some cancer cells create barriers known as "checkpoints" to block the immune system. Drugs called checkpoint inhibitors help make the cancer cells visible to the body's own immune system. Once the barrier is removed, the immune system can recognise and destroy the cancer.

Nivolumab is a checkpoint inhibitor used to treat advanced kidney cancer. Nivolumab is usually administered into a vein (intravenously). It has been shown to be effective in people with advanced kidney cancer previously treated with a tyrosine kinase inhibitor.

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. In particular, using nivolumab combined with ipilimumab, has been shown to be an effective first treatment for advanced kidney cancer. This combination of drugs is not currently subsidised on the PBS for kidney cancer, however, this may change in 2019. See Understanding Immunotherapy or listen to our podcast episode "New Cancer Treatments".

Many more targeted therapy and immunotherapy drugs are being studied in clinical trials. Talk with your doctor about the latest developments and whether you are a suitable candidate.

Side effects of immunotherapy

The side effects of immunotherapy can vary – not everyone will experience the same effects. Common side effects include fatigue, skin rash and diarrhoea. Because immunotherapy drugs stimulate the immune system, they can cause reactions such as dermatitis, hepatitis and colitis.

Radiation therapy

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 might be used in advanced kidney cancer to shrink a tumour and relieve symptoms (palliative treatment, see below).

If you have radiation therapy, you will lie on a treatment table under a machine called a linear accelerator. You will not feel anything during the treatment, which will only take a few minutes. 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 treatment sessions depends on your situation. You might have some side effects, such as fatigue, nausea, appetite loss, diarrhoea, tiredness and skin irritation. Talk to your radiation oncologist about any side effects you experience so you can get advice about how to manage them. See Understanding Radiation Therapy.

Palliative treatment

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 aim to meet your physical, emotional, practical, spiritual and social needs.

As well as slowing the spread of cancer, palliative treatment can relieve pain and help manage other symptoms. Treatment may include radiation therapy to reduce pain from cancer that has spread to the bone, arterial embolisation (a procedure that blocks the blood supply to the kidney and the tumour inside it), targeted therapy or immunotherapy. See Understanding Palliative Care, Living with Advanced Cancer, Overcoming Cancer Pain and Understanding Secondary Bone Cancer.

Key points about advanced kidney cancer

What it is

Advanced kidney cancer is cancer that has spread from the kidney to another part of the body or come back after the initial treatment.

Treatment goal

The usual goal of treatment is to control the cancer, slow down its spread and manage any symptoms.

The main treatment

The main treatment is with drugs that reach cancer cells throughout the body to control the cancer's growth and stop it spreading:

  • targeted therapy drugs block cancer cell growth by targeting specific features of cancer cells
  • immunotherapy drugs use the body's own immune system to fight cancer.

Other treatment options

Other options might include:

  • active surveillance – watching the growth of the cancer through regular check-ups before giving treatment
  • surgery – removing the primary kidney cancer (cytoreductive nephrectomy), and sometimes removing some or all of the cancer that has spread (metastasectomy)
  • radiation therapy – shrinking the tumour if it is causing symptoms
  • palliative treatment – using medical treatments to ease cancer symptoms.

Expert content reviewers:

A/Prof Declan Murphy, Urologist and Director of Genitourinary Oncology, Peter MacCallum Cancer Centre, VIC; Dr Carole Harris, Medical Oncologist, St George and Sutherland Hospitals, and Clinical Lecturer, The University of New South Wales, NSW; Caitriona Nienaber, 13 11 20 Consultant, Cancer Council WA; A/Prof Shankar Siva, Radiation Oncologist, Peter MacCallum Cancer Centre, VIC; Beth Stone, Consumer.

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