Treatment

Surgery (nephrectomy or partial nephrectomy) may be done in advanced kidney cancer at the time of diagnosis if most of the cancer is in the kidney and the person is healthy, not experiencing symptoms from the cancer, and expected to recover well enough to receive future treatment for advanced RCC. In certain situations, surgery will be done to remove the kidney cancer that has spread to other parts of the body, especially if it is small and in only one or two places. This is called a metastasectomy. Surgery may also be considered for patients who have responded well to systemic therapies (targeted therapy or immunotherapy) but still have residual cancer in their bodies, in order to remove all the known cancer.

Active surveillance for advanced RCC means a person is monitored closely with CT scans for cancer growth but does not receive treatment. This approach is considered if someone:
has no symptoms from cancer,

• the amount of cancer in the body is small,
• is elderly,
• has other medical conditions that would make surgery or drug treatment for advanced RCC difficult or risky.

Active Surveillance Summary Sheet

Drug treatments are medicines that are given intravenously or taken orally. These types of treatments are also called systemic therapies because they treat cancer cells anywhere in the body.

Drug treatment includes medicines approved by a regulatory body to be used by persons with kidney cancer. In the United States, the regulatory body is the Food and Drug Administration (FDA). In Europe, it is the European Medicines Agency (EMA).

An FDA-approved drug is one that has been tested in humans in clinical trials and found to be safe and effective for the type of cancer being treated. An investigational drug is one that is being evaluated in clinical trials to determine if it is safe and effective for cancer. Investigational drugs might be considered for certain eligible patients if other approved options have already been tried or if there is an investigational combination treatment of two approved drugs for kidney cancer. Not all oncology practices are able to offer clinical trials or investigational drugs.

Please refer to the section on drug therapy for more detailed information about each treatment approach.

Radiation is not typically used as a primary form of treatment for kidney cancer but may be used to help control symptoms from cancer that has spread to other areas, particularly the bone, brain, or spine. Radiation therapy can be particularly helpful for decreasing pain if the cancer has spread to bone or spine.

There are several different types of radiation therapy. All work on the same basic principle of using high-energy radiation to kill cancer cells or slow their rate of growth. Radiation therapy is a “localized” treatment, targeted as precisely as possible at a specific area or tumor. Radiation therapy works by damaging the DNA molecules inside the cancer cell, thereby preventing them from being able to grow and divide. The type of radiation to be used is determined by the location of the tumor in the body.

External beam radiation
External beam radiation therapy delivers a beam of radiation from a machine, through the skin, to the tumor. The exact location for the beam to target is determined by calculations during a simulation visit prior to initiating radiation therapy. The number of treatment visits is determined by the amount of radiation needed; some areas are more sensitive and will not require as much radiation as others. External beam radiation is commonly used for bone metastases to prevent the bone from fracturing if weakened by cancer or to reduce pain from the tumor.

Side effects of external beam radiation:

• While radiation may damage kidney cancer cells, it can also damage healthy, normal tissue. Side effects occur in the area treated, referred to as the “radiation field.” These side effects are temporary and vary depending on the body area being treated.

• One of the most common side effects is dry, irritated (reddened), and sensitive skin. Your radiation team will provide information and instructions for skin care and other side effects specific to your radiation treatments. Constipation or diarrhea may occur if the intestines are in the “radiation field.” Anemia (low hemoglobin), neutropenia (low white blood cell count), and thrombocytopenia (low platelet count) may occur if you are receiving radiation therapy to the pelvic bones or femur. Fatigue may develop toward the end or shortly after your treatments have finished. Fatigue can be managed with rest alternating with light activity.

• It is important to ask questions so side effects are minimal and treated early. This will help you tolerate the treatment with a minimum of side effects and complications.

Stereotactic radiosurgery
Stereotactic radiosurgery is a non-surgical technique that treats metastasized cancer. Multiple beams of high-dose radiation are directed at tumors and deliver a very high dose of radiation only to the tumor. This allows for more precise and concentrated treatment. It is often used in the brain or in the bones of the spine.

Gamma knife radiosurgery uses a gamma knife machine and is often used for small brain tumors. The patient wears a fitted head frame (helmet) and lies on a bed that slides into the machine. Radiation is delivered through ports inside the helmet, with the beams intersecting at the tumor. Another type of radiosurgery is done on a linear accelerator system used to treat larger tumors outside the brain. This machine moves around the patient to deliver beams of radiation to the tumor target.

Whole Brain Radiation Therapy (WBRT)
This type of radiation treats the whole brain. Radiation beams pass through the skull and treat the tumor or tumors, but also treat the rest of the brain in case small cancer cells are present.

Radiofrequency Ablation (RFA) and Cryoablation or Cryosurgery
Radiofrequency ablation (RFA) and cryoablation (also called cryosurgery or cryotherapy) are minimally invasive procedures that destroy or kill tumor cells without surgery or radiation. They may be used to destroy small tumors in select patients. Recovery for these procedures is generally much faster than surgery.

RFA destroys tumors with thermal energy (heat). Imaging procedures, such as computed tomography (CT), magnetic resonance imaging (MRI) or ultrasound (US), are used to guide the needle electrode into the tumor, and the electrical current or energy is passed through to heat and destroy cancerous tissue.

Cryoablation uses freezing temperatures (achieved by using liquid nitrogen or carbon dioxide) to destroy the tumor. Using imaging such as CT, MRI or US, tiny probes are passed through the skin to deliver cold to the tumor, causing it to die.

Clinical trials are research studies of treatments that are not yet approved for use by a regulatory body, but are being tested to determine if they are safe and effective to treat certain cancers.

One of the advantages of participating in a clinical trial is access to newer treatments or combinations of treatments that might be more effective than what is currently available. A potential disadvantage of participating in a clinical trial is that unknown side effects of the investigational therapy may occur or it may be ineffective to treat kidney cancer.

There are also certain eligibility criteria a patient has to meet in order to participate in a clinical trial. For example, some clinical trials only include participants who have not had any prior therapy for their cancer. Your oncology team should be able to review the potential risks and benefits of this treatment approach. See the section on clinical trials for more information.

As you adjust to your diagnosis, you may deal with several physical, emotional, and practical issues that could pose challenges. Dealing with these issues is a central part of your overall care and resources are available to help. This component of your overall health plan is called “supportive care”, or sometimes “palliative care”, and it encompasses all forms of care aimed at supporting your quality of life.

Among the important elements of supportive care are:

• managing side effects, such as nausea, pain, or fatigue
• focusing on family and work life
• maintaining nutrition and exercise
• navigating practical matters such as health insurance or treatment coverage
• helping with emotional adjustment regarding cancer diagnosis

Supportive or palliative care is not limited to terminal patients nor does it indicate an end-of-life situation – these are misconceptions. Oncology departments may have palliative care or supportive care specialists who work with patients early in their diagnosis and treatment to help promote quality of life and provide emotional support.

As you begin to create a supportive care plan, be sure to have frank discussions with your healthcare team about your needs. They should be able to address these issues or make a referral to resources that can be helpful.