Kidney Cancer: Types of Treatment

Approved by the Lineagotica Editorial Board, 10/2018

ON THIS PAGE: You will learn about the different types of treatments doctors use to treat people with kidney cancer. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for kidney cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. To learn more about clinical trials, see the About Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For kidney cancer, the health care team is usually led by a urologist, a doctor who specializes in the genitourinary tract, which includes the kidneys, bladder, genitals, prostate, and testicles, or a urologic oncologist, a doctor who specializes in treating cancers of the urinary tract. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

Descriptions of the common types of treatments used for kidney cancer are listed below. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.

Treatment options and recommendations depend on several factors, including the type, cell type, and stage of cancer, possible side effects, and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving treatment. Learn more about making treatment decisions.

Kidney cancer is most often treated with surgery, targeted therapy, immunotherapy, or a combination of these treatments. Radiation therapy and chemotherapy are occasionally used. People with kidney cancer that has spread, called metastatic cancer (see below), often receive multiple lines of therapy. This means treatments are given one after another.

Active surveillance

Sometimes the doctor may recommend closely monitoring the tumor with regular diagnostic tests and clinic appointments. This is called active surveillance. Active surveillance is effective in older adults and people who have a small renal tumor and another serious medical condition, such as heart disease, chronic kidney disease, or severe lung disease. Active surveillance may also be used for some people with kidney cancer as long as they are otherwise well and have few or no symptoms, even if the cancer has spread to other parts of the body. Systemic therapies (see "Therapies using medications," below) can be started if it looks like the disease is getting worse.

Active surveillance is not the same as watchful waiting for kidney cancer. Watchful waiting involves regular appointments to review symptoms, but patients do not have regular diagnostic tests, such as biopsy or imaging scans. The doctor simply watches for symptoms. If symptoms suggest that action is needed, then a new treatment plan is considered.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. If the cancer has not spread beyond the kidneys, surgery to remove the tumor, part or all of the kidney, and possibly nearby tissue and lymph nodes, may be the only treatment needed.

Types of surgery used for kidney cancer include the following procedures:

  • Radical nephrectomy. Surgery to remove the tumor, the entire kidney, and surrounding tissue is called a radical nephrectomy. If nearby tissue and surrounding lymph nodes are also affected by the disease, a radical nephrectomy and lymph node dissection is performed. During a lymph node dissection, the lymph nodes affected by the cancer are removed. If the cancer has spread to the adrenal gland or nearby blood vessels, the surgeon may remove the adrenal gland during a procedure called an adrenalectomy, as well as parts of the blood vessels. A radical nephrectomy is usually recommended to treat a large tumor when there is not much healthy tissue remaining. Sometimes the renal tumor will grow directly inside the renal vein and enter the vena cava on its way to the heart. If this happens, complex cardiovascular surgical techniques are needed to safely remove all disease.

  • Partial nephrectomy. A partial nephrectomy is the surgical removal of the tumor. This type of surgery preserves kidney function and lowers the risk of developing chronic kidney disease after surgery. Research has shown that partial nephrectomy is effective for T1 tumors whenever surgery is possible. Newer approaches that use a smaller surgical incision, or cut, are associated with fewer side effects and a faster recovery.

  • Laparoscopic and robotic surgery (minimally invasive surgery). During laparoscopic surgery, the surgeon makes several small incisions in the abdomen, rather than the 1 larger incision used during a traditional surgical procedure. The surgeon then inserts telescoping equipment into these small keyhole incisions to completely remove the kidney or perform a partial nephrectomy. Sometimes, the surgeon may use robotic instruments to perform the operation. This surgery may take longer but may be less painful. Laparoscopic and robotic approaches require specialized training. It is important to discuss the potential benefits and risks of these types of surgery with your surgical team and to be certain that the team has experience with the procedure.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Non-surgical tumor treatments

Sometimes surgery is not recommended because of characteristics of the tumor or the patient’s overall health. The following procedures may be recommended instead:

  • Radiofrequency ablation. Radiofrequency ablation (RFA) is the use of a needle inserted into the tumor to destroy the cancer with an electrical current. The procedure is performed by an interventional radiologist or urologist. The patient is sedated and given local anesthesia to numb the area. In the past, RFA has only been used for patients who were too sick to have surgery. Today, most of these patients' health is managed with active surveillance (see above).

  • Cryoablation. Cryoablation, also called cryotherapy or cryosurgery, is the freezing of cancer cells with a metal probe inserted through a small incision. The metal probe is placed into the cancerous tissue. A CT scan and ultrasound are used to guide the probe. The procedure requires general anesthesia for several hours and is performed by an interventional radiologist. Some surgeons combine this technique with laparoscopy to treat the tumor, but there is not much long-term research evidence to prove that it is effective.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for kidney cancer include:

  • Targeted therapy

  • Immunotherapy

  • Chemotherapy

Each of these types of therapies is discussed below in more detail. A person may receive only 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. They can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Targeted therapy (updated 07/2019)

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells. These drugs are becoming more important in the treatment of kidney cancer.

Not all tumors have the same targets. Research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

Targeted therapy for kidney cancer includes:

  • Anti-angiogenesis therapy. This type of treatment focuses on stopping angiogenesis, which is the process of making new blood vessels. Most clear cell kidney cancers have mutations of the VHL gene, which causes the cancer to make too much of a certain protein, known as vascular endothelial growth factor (VEGF), controlling the formation of new blood vessels. VEGF can be blocked with certain drugs. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. There are 2 ways to block VEGF, with small molecule inhibitors of the receptors (VEGFR) or with antibodies directed against these receptors.

    One antibody called bevacizumab (Avastin) has been shown to slow tumor growth for people with metastatic renal cell carcinoma. Bevacizumab combined with interferon (see “Immunotherapy” below) slows tumor growth and spread. There are 2 similar drugs, called bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), that have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of metastatic kidney cancer. These are called biosimilars, and they are similar in their action to the original bevacizumab antibody.

    The other way to block VEGF is with tyrosine kinase inhibitors (TKIs). Axitinib (Inlyta), cabozantinib (Cabometyx), pazopanib (Votrient), sorafenib (Nexavar), and sunitinib (Sutent) are TKIs that may be used for treatment for clear cell kidney cancer. Side effects of TKIs may include diarrhea, high blood pressure, and tenderness and sensitivity in the hands and feet.

  • mTOR inhibitors. Everolimus (Afinitor) and temsirolimus (Torisel) are drugs that target a certain protein that helps kidney cancer cells grow, called mTOR. Studies show that these drugs slow kidney cancer growth.

  • Combined therapies. In 2019, the FDA approved 2 combination treatments for the first treatment for advanced renal cell carcinoma. The first combination includes axitinib and pembrolizumab (Keytruda), which is an immune checkpoint inhibitor (read below to learn more about immunotherapy). The second combination uses 2 targeted therapies, axitinib and avelumab (Bavencio). Axitinib is an anti-angiogenesis therapy. Both pembrolizumab and avelumab target the PD-L1 protein in cancer cells. These treatment combinations work regardless of whether the tumor expresses the PD-L1 protein, so people who receive this treatment will not be tested for PD-L1.

Talk with your doctor about possible side effects for each specific medication and how they can be managed.

Immunotherapy (updated 04/2019)

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

  • Interleukin-2 (IL-2, Proleukin). IL-2 is a type of immunotherapy that has been used to treat later-stage kidney cancer. It is a cellular hormone called a cytokine that is produced by white blood cells. It is important in immune system function, including the destruction of tumor cells.

    High-dose IL-2 can cause severe side effects, such as low blood pressure, excess fluid in the lungs, kidney damage, heart attack, bleeding, chills, and fever. Patients may need to stay in the hospital for up to 10 days during treatment. However, some symptoms may be reversible. Only centers with expertise in high-dose IL-2 treatment for kidney cancer should recommend IL-2. High-dose IL-2 can cure a small percentage of patients with metastatic kidney cancer. Some centers use low-dose IL-2 because it has fewer side effects, although it is not as effective.

  • Alpha-interferon. Alpha-interferon is used to treat kidney cancer that has spread. Interferon appears to change the proteins on the surface of cancer cells and slow their growth. Although it has not proven to be as beneficial as IL-2, alpha-interferon has been shown to lengthen lives when compared with an older treatment called megestrol acetate (Megace).

  • Immune checkpoint inhibitors. A form of immunotherapy, called immune checkpoint inhibitors, is being tested in kidney cancer. The FDA has approved a combination of 2 immune checkpoint inhibitors, nivolumab (Opdivo) and ipilimumab (Yervoy), to treat certain patients with advanced renal cell carcinoma that has not been previously treated. Additional research had previously shown that nivolumab given as a single drug through the vein every 2 weeks helped certain patients who had received prior treatment live longer than patients treated with the targeted therapy everolimus. The FDA has also approved another checkpoint inhibitor, pembrolizumab (Keytruda), plus a targeted therapy, axitinib (see above), as a first treatment for people with advanced renal cell carcinoma. A lot of research is being done on these types of drugs for the treatment of kidney cancer (see Latest Research).

Different types of immunotherapy can cause different side effects. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by ending the cancer cells’ ability to grow and divide.

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time.

Although chemotherapy is useful for treating most types of cancer, kidney cancer is often resistant to chemotherapy. Researchers continue to study new drugs and new combinations of drugs. For some patients, the combination of gemcitabine (Gemzar) with capecitabine (Xeloda) or fluorouracil (5-FU, Adrucil) will temporarily shrink a tumor.

It is important to remember that transitional cell carcinoma, also called urothelial carcinoma, and Wilms tumor are much more likely to be successfully treated with chemotherapy.

The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These side effects usually go away after treatment is finished.

Learn more about the basics of chemotherapy.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist.

Radiation therapy is not effective as a primary treatment for kidney cancer. It is very rarely used alone to treat kidney cancer because of the damage it causes to the healthy kidney. Radiation therapy is used only if a patient cannot have surgery and, even then, usually only on areas where the cancer has spread and not on the primary kidney tumor. Most often, radiation therapy is used when the cancer has spread to help ease symptoms, such as bone pain or swelling in the brain.

Learn more about the basics of radiation therapy.

Care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatments intended to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care is any treatment that focuses on reducing symptoms, improving quality of life, and supporting patients and their families. Any person, regardless of age or type and stage of cancer, may receive palliative care. It works best when palliative care is started as early as needed in the cancer treatment process. People often receive treatment for the cancer at the same time that they receive treatment to ease side effects. In fact, people who receive both at the same time often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional support, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, or radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of the specific treatment plan and palliative care options. During and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it can be addressed as quickly as possible. Learn more about palliative care.

Metastatic kidney cancer

If cancer spreads to another part in the body from where it started, doctors call it metastatic cancer. This is a systemic disease that requires systemic therapy, such as targeted therapy or immunotherapy. Often, doctors may ask a surgeon to remove the kidney with the tumor in an operation called a cytoreductive nephrectomy. This prevents pain and bleeding during systemic treatment and is associated with a better prognosis.

Metastatic kidney cancer most commonly spreads to the lungs, but it can also spread to the lymph nodes, bones, liver, brain, skin, and other areas in the body. For kidney cancer that has spread to 1 specific part of the body, such as a lung, surgery may be able to completely remove the cancer. This operation is called a metastasectomy, and it can help some patients live longer. If the cancer has spread to many areas beyond the kidney, it is more difficult to treat. Surgery is often not helpful, and systemic therapy using medications may be given instead.

If the cancer has spread, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Currently, the most effective treatment for metastatic kidney cancer is targeted therapy that slows or prevents tumor growth and blood vessel formation. These drugs have been shown to lengthen life when compared with standard treatment. Palliative care is also important to help relieve symptoms and side effects.

For most people, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. You and your family are encouraged to talk about how you feel with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions are permanent, it is important to talk with your doctor about the possibility of the cancer returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence). If you have had a partial nephrectomy already, a new tumor may form in that kidney. The recurrent tumor can be removed with another partial nephrectomy or with a radical nephrectomy.

When there is a recurrence, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above, such as surgery, targeted therapy, or immunotherapy, but they may be used in a different combination or given at a different pace. If you have had a partial nephrectomy, a new tumor may form that can be treated with another partial nephrectomy or radical nephrectomy. Your doctor may also suggest clinical trials that are studying newly developed systemic therapies or new combinations of such drugs. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent cancer often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not work

Recovery from cancer is not always possible. If the cancer cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people, advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

People who have advanced cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. Use the menu to choose a different section to read in this guide.

Anti-angiogenesis therapy. This type of treatment focuses on stopping angiogenesis, which is the process of making new blood vessels. Most clear cell kidney cancers have mutations of the VHL gene, which causes the cancer to make too much of a certain protein, known as vascular endothelial growth factor (VEGF), controlling the formation of new blood vessels. VEGF can be blocked with certain drugs. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. There are 2 ways to block VEGF, with small molecule inhibitors of the receptors (VEGFR) or with antibodies directed against these receptors.

One antibody called bevacizumab (Avastin) has been shown to slow tumor growth for people with metastatic renal cell carcinoma. Bevacizumab combined with interferon (see “Immunotherapy” below) slows tumor growth and spread. There are 2 similar drugs, called bevacizumab-awwb (Mvasi) and bevacizumab-bvzr (Zirabev), that have been approved by the U.S. Food and Drug Administration (FDA) for the treatment of metastatic kidney cancer. These are called biosimilars, and they are similar in their action to the original bevacizumab antibody.