Surgery

Surgery is the primary treatment for kidney cancer that has not spread.

Depending on the stage and location of the cancer and other factors, surgery may remove the tumor or tumors along with some of the surrounding kidney tissue (known as a partial nephrectomy), or the entire kidney (known as a radical nephrectomy). The adrenal gland (the small gland that sits on top of each kidney) and fatty tissue around the kidney may also be removed.

A “laparoscopic” approach is often used in surgery. With this approach, the surgeon makes several small incisions in the abdomen to insert a tiny light, a camera, and instruments used to view and remove the tumor. This type of surgery has been shown to be just as effective as traditional surgery, with an easier recovery.

If the cancer has spread (metastasized) and formed tumors in other parts of the body, the original tumor in the kidney is often still treated with surgery, followed by other forms of treatment.

Immunotherapy

In immunotherapy treatment, medications are used to increase the body’s natural ability to fight cancer.

Immunotherapy continues to be a promising area of research in the treatment of kidney cancer, including the use of “immune checkpoint inhibitors.” These are treatments that work by targeting molecules that serve as checks and balances on immune responses.

In November 2015, the U.S. Food and Drug Administration (FDA) approved the immunotherapy drug nivolumab (Opdivo) to treat patients whose metastatic kidney cancer progressed while on an anti-angiogenic therapy (treatments designed to “starve” tumors). Nivolumab is a monoclonal antibody that neutralizes the PD-1 protein, an element of tumors that allows them to evade the immune system. Nivolumab appears to result in major shrinkage in about one quarter of people who receive this drug.

Two other immunotherapy drugs—interleukin-2 (Proleukin) and interferon alfa (Intron A, Roferon-A)—can cause some kidney tumor metastases (tumors in other parts of the body) to shrink by more than half. However, this type of immunotherapy works in only 10 percent to 15 percent of patients.

Immunotherapy trials currently underway include:

• A phase III study of nivolumab (a PD-1 antibody) in combination with ipilimumab (a CTLA-4 antibody) as compared to the targeted treatment sunitinib in patients with previously untreated advanced or metastatic renal cell carcinoma.
• A phase III study of atezolizumab (a PD-L1 antibody) in combination with the targeted treatment bevacizumab as compared to sunitinib in patients with untreated advanced renal cell carcinoma.

Targeted Treatments

Targeted treatments focus on specific molecules and cell mechanisms thought to be important for cancer cell survival and growth, taking advantage of what researchers have learned in recent years about how kidney tumors grow.

Some targeted treatments are designed to stop angiogenesis (the development of new blood vessels). Between 2005 and 2012, five anti-angiogenesis drugs were approved by the FDA for the treatment of metastatic (advanced) kidney cancer: Sunitinib (Sutent), Pazopanib (Votrient), Axitinib (Inlyta) and Sorafenib (Nexavar) work by blocking the action of proteins released by tumors which promote the formation of blood vessels, thereby “starving” the tumors. These blocked proteins include vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF). The fifth anti-angiogenesis drug, bevacizumab, acts by binding directly to circulating VEGF and inactivating it.

Other targeted treatments approved for treatment of metastatic kidney cancer work by blocking the actions of the protein mTOR (which activates mechanisms in cells that promote cancer growth): temsirolimus (Torisel), and everolimus (Afinitor).

In 2016, the FDA approved two targeted treatments to treat patients with advanced renal cell carcinoma who previously received anti-angiogenic therapy:

• In April 2016, the FDA granted approval to cabozantinib (Cabometyx), a drug that targets multiple tyrosine kinases, enzymes that are part of many cell functions, including signaling, growth, and division. At too-high levels, these enzymes may be involved in the development of renal cell carcinoma, and blocking them may help keep cancer cells from growing.

• In May 2016, the FDA approved the combination of targeted therapies levatinib (Lenvima) and everolimus (Afinitor), the first regimen that targets both tyrosine kinases and mTOR, a protein that acts like a master switch, “turning on” different mechanisms in cells that promote cancer growth.

Targeted treatments are being used in clinical trials and in combination with other types of cancer treatment. New treatments are continually being developed and researched.

Chemotherapy

Chemotherapy is not a standard treatment for kidney cancer, as cancer cells are usually resistant to chemotherapy drugs. Some drugs, such as vinblastine, floxuridine, 5-fluorouracil (5-FU), capecitabine, and gemcitabine have been shown to help a small percentage of patients. Chemotherapy is often used only after targeted therapy and/or immunotherapy has already been tried.

All cancer treatments can cause side effects. It’s important that you report any side effects you experience to your health care team so they can help you manage them. Report them right away—don’t wait for your next appointment. Doing so will improve your quality of life and allow you to stick with your treatment plan. It’s important to remember that not all patients experience all side effects, and patients may experience side effects not listed here.

Side Effects of Immunotherapy and Targeted Therapy

Immunotherapy travels through the bloodstream, helping to prompt an immune response. Although immunotherapy drugs are generally fairly well-tolerated, certain side effects may be experienced, including fatigue, decreased appetite, and digestive tract symptoms. Rare and serious side effects include the development of an inflammation in the lungs or in the colon, causing difficulty breathing or severe diarrhea. These symptoms must be treated immediately.

Targeted therapy drugs don’t have the same effect on the body as do chemotherapy drugs, but they can still cause side effects. Common side effects of targeted therapy include diarrhea, liver problems (such as hepatitis and elevated liver enzymes), problems with blood clotting and wound healing, and high blood pressure.

Managing Digestive Tract Symptoms

Nausea and vomiting

• Avoid food with strong odors, as well as overly sweet, greasy, fried, or highly seasoned food.
• Eat meals cold or at room temperature, which often makes food more easily tolerated.
• Nibble on dry crackers or toast. These bland foods are easy on the stomach.
• Having something in your stomach when you take medication may help ease nausea.

Diarrhea

• Drink plenty of water. Ask your doctor about using drinks such as Gatorade which provide electrolytes as well as liquid. Electrolytes are body salts that must stay in balance for cells to work properly.
• Over-the-counter medicines such as loperamide (Imodium A-D and others) and prescription drugs are available for diarrhea but should be used only if necessary. If the diarrhea is bad enough that you need medicine, discuss it with your doctor or nurse.
• Choose foods that contain soluble fiber—for example beans, oat cereals, oranges, and flaxseeds. High-pectin foods such as peaches, apples, oranges, grapefruit, bananas, and apricots can also help to avoid diarrhea.
• Avoid food high in refined sugar and those sweetened with sugar alcohols such as sorbitol and mannitol. Look for this low-calorie sweetener on food labels; the names of this type of sweetener usually end with the letters “ol.”
• Low fat food choices are less likely to cause diarrhea than fatty, greasy, or fried foods. The fats you eat should come from healthy sources, such as olive oil, canola oil, avocado, olives, nuts, and seeds.
• Limit or avoid lactose, especially if you are lactose-intolerant. There are plant-based milk alternatives you can try, such as soy or rice milk. If lactose is an essential part of your diet, there are dairy products with added lactase (which breaks down lactose) and dietary lactase supplements.

Managing loss of appetite

• To help maintain your weight, eat small meals throughout the day. That’s an easy way to take in more protein and calories. Try to include protein in every meal.
• To keep from feeling full early, avoid liquids with meals or take only small sips (unless you need liquids to help swallow). Drink most of your liquids between meals.
• Be as physically active as you can. Sometimes, taking a short walk an hour or so before meals can help you feel hungry.
• Keep high-calorie, high-protein snacks on hand such as hard-boiled eggs, peanut butter, cheese, ice cream, granola bars, liquid nutritional supplements, puddings, nuts, canned tuna, or trail mix.
• Eat your favorite foods any time of the day. For example, if you like breakfast foods, eat them for dinner.
• If you are struggling to maintain your appetite, talk to your health care team about whether appetite-building medication could be right for you.

Managing Fatigue

Fatigue (extreme tiredness not helped by sleep) is one of the most common side effects of many cancer treatments. If you are taking a medication, your doctor may lower the dose of the drug, as long as it does not make the treatment less effective. If you are experiencing fatigue, talk to your doctor about whether taking a smaller dose is right for you.

There are a number of other tips for reducing fatigue:

• Take several short naps or breaks.
• Take short walks or do some light exercise, if possible.
• Try easier or shorter versions of the activities you enjoy.
• Ask your family or friends to help you with tasks you find difficult or tiring.
• Save your energy for things you find most important.

Managing Pain

To help your doctor prescribe the best medication, it’s useful to give an accurate report of your pain. Keep a journal that includes information on:

• Where the pain occurs.
• When the pain occurs.
• How long it lasts.
• How strong it is on a scale of 1 to 10, with 1 being the least amount of pain and 10 the most intense.
• What makes the pain feel better and what makes it feel more intense.

There are a number of options for pain relief, including prescription and over-the-counter medications. It’s important to talk to a member of your health care team before taking any over the counter medication, to determine if they are safe and will not interfere with your treatments. Many pain medications can lead to constipation, which may make your pain worse. Your doctor can prescribe medications that help to avoid constipation.

Physical therapy, acupuncture, and massage may also be of help in managing your pain. Consult with a member of your health care team before beginning any of these activities.

Communicating with Your Health Care Team

As you manage your kidney cancer, it’s important to remember that you are a consumer of health care. The best way to make decisions about health care is to educate yourself about your diagnosis and get to know the members of your health care team, including doctors, nurses, dietitians, social workers and patient navigators.

In addition to creating a treatment summary, here are some tips for improving communication with your health care team:

Start a health care journal. Having a health care journal or notebook will allow you to keep all of your health information in one place. You may want to write down the names and contact information of the members of your health care team, as well as any questions for your doctor. Keep a diary of your daily experiences with symptoms related to your illness or treatment. You can separate your journal or notebook into different sections to help keep it organized.

Prepare a list of questions. Before your next medical appointment, write down your questions and concerns. Because your doctor may have limited time, you should ask your most important questions first, and be as specific and brief as possible.

Bring someone with you to your appointments. Even if you have a journal and a prepared list of questions or concerns, it’s always helpful to have support when you go to your appointments. The person who accompanies you can serve as a second set of ears. He or she may also think of questions to ask your doctor or remember details about your symptoms or treatment that you may have forgotten.

Write down your doctor’s answers. Taking notes will help you remember your doctor’s responses, advice, and instructions. If you cannot write down the answers, ask the person who accompanies you to do that for you. If you have a mobile device, ask if you can use it to take notes. Writing notes will help you review the information later.

Record your visit if your doctor allows it. Recording the conversation with your doctor gives you a chance to hear specific information again or share it with family members or friends.

Incorporate other health care professionals into your team. Your oncologist and oncology nurse are essential members of your health care team, but there are other health care professionals who can help you manage your care:

• Your primary care physician should be kept updated about your kidney cancer treatment and any test results.

• Your local pharmacist is a great source of knowledge about the medications you are taking; have all of your prescriptions filled at the same pharmacy to avoid the possibility of harmful drug interactions.

• Make sure your oncologist knows of any other medical conditions you have, or any pain you are experiencing, so that they can consult with your primary care physician or your specialist if needed.

Remember, there is no such thing as over-communication. Your health care team wants to know about how you’re feeling overall, which includes your level of pain, your energy level, your appetite, and your mood and spirits.

Frequently Asked Questions

Q. Does kidney cancer run in families?

A. There is recent research that indicates there might be a genetic component in kidney cancer. If you have multiple family members with kidney cancer, and you have also been diagnosed, talk to your doctor about the possibility of meeting with a genetic counselor. It’s important to note that there are risk factors for kidney cancer not related to heredity, including smoking, obesity, and high blood pressure.

Q. What questions should I ask my doctor before I start my kidney cancer treatment?

A. Work with your doctor to define the goals of treatment and discuss what you may expect during your treatment. Questions you may want to ask include:

• How can I best stay on my treatment plan?
• How does the drug work, and what side effects can I expect?
• What will be my schedule of visits?
• What other medications will I need to take?

Q. I’m concerned about dehydration. What can I do to avoid it?

A. The drugs that are used to treat cancer can make you feel dehydrated. Keeping a water bottle with you is one easy way to help you stay well-hydrated. Hydration can also be provided by liquids other than water, such as juice, soup, and fruit “smoothies.” Be sure to stop taking in fluids early enough in the evening so that your sleep is not disrupted.

Q. I have tried all of the existing FDA -approved drugs for kidney cancer. Are there any newer drugs that I can try?

A. Talk to your doctor about enrolling in a clinical trial. Your doctor will be able to tell you about clinical trial requirements and about specific kidney cancer trials that are available. In the Resources section of this booklet, there is a list of websites that can help you and your doctor locate clinical trials.