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. A tiny light, a camera and surgical instruments are inserted to view and remove the tumor. This type of surgery has been shown to be as effective as traditional surgery, with an easier recovery.

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

Immunotherapy

Our immune system works constantly to keep us healthy. It recognizes and fights against danger, such as infections, viruses and growing cancer cells. In general terms, immunotherapy uses our own immune system as a treatment against cancer.

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 prevent the development of blood vessels). Nivolumab is a monoclonal antibody that neutralizes PD-1, a protein which tumors use to evade the immune system.

In April 2018, the FDA approved the combination of nivolumab and another immunotherapy drug, ipilimumab (Yervoy), as an initial treatment for certain people with advanced kidney cancer. Ipilimumab is thought to help the immune system destroy cancer cells by blocking the action of CTLA-4, a protein that normally helps keep immune system cells (called T-cells) in check.

Targeted Therapy

Targeted therapies 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.

The targeted therapies temsirolimus (Torisel) and everolimus (Afinitor) are approved by the FDA for the treatment of kidney cancer. Both of these drugs work by blocking the actions of mTOR, a protein which activates mechanisms in cells that promote cancer growth.

Some targeted therapies are designed to stop angiogenesis. 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. The protein pathways that are blocked include vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF).
• Bevacizumab (Avastin) acts by binding directly to and inactivating VEGF.

In November 2017, the FDA expanded the approval of sunitinib to include treatment for people who underwent a radical nephrectomy and are at high risk of kidney cancer recurrence. In 2016, the FDA approved two targeted therapies to treat people 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 growth and division). At too-high levels, these enzymes can 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 the targeted therapies lenvatinib (Lenvima) and everolimus (Afinitor), the first regimen that targets both tyrosine kinases and the protein mTOR.

Chemotherapy

Chemotherapy is not a standard treatment for most kidney cancers, as kidney 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 with the more common renal cell carcinomas. In these cases, chemotherapy is often used only after targeted therapy and/or immunotherapy has already been tried. However, chemotherapy is often the first and best option for some very rare kidney cancers such as renal medullary carcinoma, collecting duct carcinoma, Wilms tumors and malignant rhabdoid tumors.

All cancer treatments can cause side effects. It’s important that you report any side effects that 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.

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, contact a member of your health care team.
• Choose foods that contain soluble fiber, like beans, oat cereals and flaxseed, and high-pectin foods such as peaches, apples, oranges, bananas and apricots.
• Avoid foods high in refined sugar and those sweetened with sugar alcohols such as sorbitol and mannitol.

Loss of appetite

• Eating small meals throughout the day is an easy way to take in more protein and calories, which will help maintain your weight. 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.
• 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.
• 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 during the day.
• Take 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.

There are also prescription medications that may help, such as modafinil. Your health care team can provide guidance on whether medication is the right approach for your individual circumstances.

Managing Pain

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 to make sure they 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.

As you manage your lung 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 the members of your health care team, including nurses, social workers and patient navigators.

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 cancer and 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, 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 diagnosis and treatment.

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.

Frequently Asked Questions

Q: Does kidney cancer run in families?

A: There is recent research indicating there might be a hereditary component in some cases of kidney cancer. If you have a family history of kidney cancer and have also been diagnosed, or if you were diagnosed with kidney cancer at the age if 50 or younger, you should talk to your doctor about the possibility of meeting with a genetic counselor. It’s important to note that there are many risk factors for kidney cancer not related to heredity, including smoking, obesity and high blood pressure.

Q: Should a person diagnosed with kidney cancer seek a second opinion?

A: At the time of diagnosis, it makes sense to seek a consultation from a major cancer center or a group of physicians who are experts in treating kidney cancer. Another time to seek a consultation or second opinion is if the cancer is not responding to treatment and/or if a change in treatment is warranted. Discussions can include possible changes in treatment approaches and whether participation in a clinical trial should be considered.

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

A: It’s important to work with your doctor and other members of your health care team 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 Gatorade, 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: What is a treatment summary and why is it important?

A: A treatment summary, sometimes called a “shadow chart,” is a document that you create and keep in your possession. Maintaining your own records allows you and your family members instant access to the specifics of your diagnosis and treatment. A treatment summary should include:

• Your name and date of birth
• Date of diagnosis
• Name, affiliation and contact information of the doctor who gave the diagnosis
• Prescribed therapy/therapies; include start and stop dates and dosages when appropriate
• Dates and types of post-diagnosis testing, and the results
• Other medication and supplements you are taking
• Names, affiliations, and contact information of all members of your health care team

Talk to your doctor or a member of your health care team about your intention to create a treatment summary, and ask them what else they suggest be included. Take your treatment summary with you when you visit any doctor, not just your oncologist.