Your doctors will discuss treatment choices and the expected results, and will work with you, your family and supporters to develop a plan that fits your situation.
Your treatment will depend on the type of kidney cancer, your general health and the stage of the cancer. All treatment has benefits and side effects, which need to be discussed with your cancer care team.
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For localised kidney cancer
Strange as it may seem, in some people with small (stage 1) kidney cancers, the first best treatment is observation, also referred to as ‘active surveillance’. If you are older, or have significant medical problems, it may be safer to first carefully watch the cancer, along with multiple scans and multiple visits to the cancer specialist.
Because many kidney cancers are discovered by accident on scans that were recommended for other reasons, a number of small kidney lumps are detected. Kidney cancers that are smaller than three centimetres are very unlikely to spread elsewhere, and sometimes the risk of an operation outweighs the benefits. People who choose active surveillance with their doctors must continue to have regular follow-up care in case the cancer starts to grow.
With a larger or growing cancer in the kidney, surgery is usually the first course of treatment. Surgery to remove kidney cancers is performed by a specialist surgeon called a urologist.
Surgery may either remove just a part of the kidney, called a partial nephrectomy, or the entire kidney, called a radical nephrectomy. This might need to be done with a large incision (an open nephrectomy) or may be able to be done by keyhole surgery (a laparoscopic nephrectomy), which results in a shorter hospital stay and quicker recovery.
If the cancer is small (stage 1, less than seven centimetres) a partial nephrectomy may be possible, where the remaining normal kidney can be spared. If the cancer is larger (stage 2) or has started to spread nearby (stage 3), then the whole kidney is usually removed with a radical nephrectomy.
If you lose one kidney, your remaining kidney gets bigger and heavier. It works harder and can provide up to 75 per cent of normal kidney function, rather than the expected 50 per cent. Most people can live quite normally with just one functioning kidney.
In some people, an operation is not advised due to their age or other medical problems. It may be still possible to treat a localised kidney cancer without surgery, using other procedures. These include radiofrequency ablation, where a needle containing a microwave antenna is inserted into the cancer under local anaesthetic, and the cancer is ‘cooked’ from the inside. Other new procedures, like special targeted radiation therapy, are being tested in clinical trials.
For advanced kidney cancer
If you have advanced kidney cancer, where the cancer has spread to distant organs, it is usually not curable. The goal of treatment is therefore to make life as long and as normal as possible.
Combinations of different treatments may be recommended by your medical team, which will include your urologist and other cancer specialists such as medical oncologists who prescribe anti-cancer medications and radiation oncologists who treat people with radiation.
Throughout, this team of specialists will work with your family doctor to help you control your symptoms and live as normal a life as possible.
Treatments for advanced kidney cancer include:
Observation – In some people, the cancer might be growing and spreading so slowly that the right first option is to watch carefully. This is especially the case when the cancer has been discovered by accident. If the cancer starts to grow quickly, or cause symptoms, then active treatments will be recommended.
A small percentage of patients might live without problems from the cancer for a very long time, so in case this applies to you, your doctor might advise you to observe for a short period of time.
Clinical trial – A clinical trial is a way of testing new treatments, or old treatments used in a new way. Clinical trials are not right for every person, and not every person is right for a clinical trial. If a clinical trial is available it can be an interesting opportunity to consider.
The hope is that the new treatment will improve on standard treatments, but sometimes it works no better. Talk to your doctor to find out about clinical trials. You can see a list of Australian kidney cancer trials (that we are aware of).
Surgery – Surgery does not usually cure kidney cancer that has spread but it may be recommended to prevent symptoms and problems from the cancer. However, if the kidney cancer has only spread to a few other spots, and your health is otherwise good, there is some evidence that removing the primary cancer improves survival and helps other treatments work better. This is known as cytoreductive nephrectomy and would be performed by your urologist.
In a very small number of people, the cancer spreads to only one or two places; if this is the case it can be possible to try to surgically remove all the cancers (a metastatecomy).
Tablets that block blood vessels – Chemotherapy is not used in kidney cancer. The current medical treatment for kidney cancer is based on tablets that stop blood supply to the cancer, which slows or stops the growth of the tumour, and sometimes causes it to shrink. These tablets target specific signals within the cancer, and are also called targeted therapies.
Other names for this group of drugs are anti-angiogenic therapies and tyrosine kinase inhibitors. These tablets are not chemotherapy but they do have side effects.
Tablets that block a cancer’s growth – A second group of medicines for kidney cancer, known as mTOR inhibitors, work by blocking a different signal, but these are not as potent so they are used only if the tablets that block the blood supply have stopped working.
In Australia these tablet treatments are reimbursed by the Pharmaceutical Benefits Scheme, but only for people with the clear cell variant of kidney cancer; treatment for the rarer types of kidney cancer is more challenging.
Immunotherapy – Kidney cancer is sometimes susceptible to the body’s own immune system. Historically, immunotherapy has been used in a small number of people with kidney cancer. The treatment used substances that are naturally produced within the body, such as interferon and interleukin, to encourage the immune system to fight disease.
This kind of immunotherapy can have many side effects and is very expensive, so is not a standard treatment in Australia.
New kinds of immune therapy are being tested in clinical trials in kidney cancer, and have shown positive results at the completion of a clinical trial phase.
Once these drugs have been successfully tested the drug company can apply to have it approved for use in Australia through the Therapeutic Goods Administration. If this is successful they can apply to have it listed on the Pharmaceutical Benefits Scheme which makes it cheaper for people to access the drug.
In some circumstances drugs can be temporarily accessed by patients via a compassionate access program. This program offers patients the opportunity to access a drug either free of charge or at a discounted price when it is not available on the general market.
These newer treatments, known as checkpoint antibodies, have shown encouraging results in other cancers like melanoma. They accelerate the immune system by ‘cutting the brake cables’, activating the immune system and stopping the cancer from deactivating the immune system.
Whilst not all immunotherapy drugs are widely available, it is a good idea to speak to your health care team to explore all available options in this rapidly moving space.
Radiation therapy – With this treatment, high-energy radiation is used to kill cancer cells. Radiation can be very helpful if the cancer causes a lot of problems in one location, such as cancer in the bone causing pain, cancer in the kidney causing bleeding, cancer in the brain causing swelling. Radiation is predominantly used as a means of controlling symptoms such as pain.
Palliative care – Palliation doesn’t mean the ‘end of the road’ or that the cancer is terminal. Palliative care is the combination of treatments that your medical team recommends to alleviate your symptoms and improve your quality of life.
Your family doctor, medical oncologist and other doctors will help you with this. Sometimes palliative care physicians and nurses are also consulted and they can often provide specialised advice.
Fact sheet: Treatment for Advanced Kidney Cancer