Advanced Kidney Cancer: Immunotherapy, Targeted Therapy and the Role of Surgery

Hearing that kidney cancer has spread is frightening. It helps to know that treatment has changed a great deal over the last decade. Many people with advanced (metastatic) kidney cancer now live for years with their disease controlled, and some are treated with the intention of achieving long remissions. This article explains the main options so you can ask better questions.

Key points

• The main medicines are immunotherapy and targeted therapy, often combined.
• The choice depends on the risk group of the cancer, your general health, and cost and availability.
• Surgery and radiation still have a role in selected people.
• Treatment is decided by a team, and is reviewed with scans every few weeks to months.

What does "advanced" mean?

It means the cancer has spread beyond the kidney, usually to the lungs, lymph nodes, bones, liver or other places. Many kidney cancers are found early, but about one in four people have, or later develop, spread. Even then, the situation varies widely: a few small spots in the lungs behave very differently from widespread disease.

How the risk is assessed

Doctors group people into favourable, intermediate or poor risk using a few simple factors: how long since the diagnosis, general fitness, blood counts, calcium and other blood tests. This grouping helps decide the most suitable medicine and gives an idea of what to expect. It is a guide for the group and not a prediction for one person.

Immunotherapy

These medicines (such as nivolumab, ipilimumab and pembrolizumab) release the body's own immune system to recognise the cancer. They are given by drip every few weeks. Their side effects are different from chemotherapy: they come from the immune system being over-active, and can affect the skin, bowel, liver, thyroid, lungs or other organs. Most are manageable if they are reported early, so you will be asked to call at the first sign of a new symptom such as diarrhoea, rash, breathlessness or severe tiredness.

Targeted therapy

Tablets taken daily (such as sunitinib, pazopanib, axitinib or cabozantinib) block the blood supply and growth signals of the cancer. Common side effects include high blood pressure, tiredness, diarrhoea, sore mouth, and sore hands and feet. These can often be managed by adjusting the dose and by treating the symptoms. Regular blood tests and blood pressure checks are part of treatment.

Combinations

For many people, the best results come from combining an immunotherapy drug with another immunotherapy drug, or with a targeted tablet. Combination choices depend on risk group and on the other illnesses you have. In selected people with slow-growing disease and no symptoms, careful observation can be reasonable at the start.

What is the role of surgery?

• Removing the kidney when the cancer has spread: once routine, this is now considered more selectively. It may help people in good health with limited spread, and is often decided after treatment has started and responded.
• Removing a single or a few spots (metastasectomy): for some people, removing a limited number of lung, bone or other spots can offer long control.
• Surgery for symptoms: for example to stabilise a weak bone or relieve a blocked passage.

The role of radiation

Focused radiation (stereotactic radiotherapy) can treat small numbers of spots in the bone, brain or elsewhere with very few sessions, and conventional radiation can ease pain from bone spread. Used alongside medicines, it can delay a change of treatment.

Cost and access

Some of these medicines are expensive. There are generic versions of some tablets, patient assistance programmes, and insurance or government schemes that may help. Please ask your oncologist and hospital about options early, because stopping or delaying treatment for cost reasons without discussion can be harmful.

Questions to ask

• Which risk group am I in, and what does that mean for the choice of treatment?
• What are the options, their side effects and approximate cost?
• Is there any role for surgery or radiation in my situation?
• How will we know it is working, and when will we review?
• Who do I contact between visits if I feel unwell?

If you are looking for a clear explanation of your own reports, or a second opinion on a treatment plan, you can ask for a second opinion. For the stages of kidney cancer and what each means, see the kidney cancer guide by stage.

This article is general information. It does not replace advice from your own doctor, who knows your reports and your health.