It may seem strange, but for some people with small (stage 1) kidney cancers, the first best treatment is often observation, or “active surveillance”.
If you are older, or have significant medical problems, it may be safer to first carefully watch the cancer, with multiple scans and multiple visits to the cancer specialist. Because many kidney cancers are discovered by accident on scans that were recommended for other reasons, a number of small kidney lumps are now being detected. Kidney cancers that are smaller than 3 cm are very unlikely to spread elsewhere, and sometimes the risks of an operation outweigh the benefits of surgery. People who choose active surveillance with their doctors must continue to have regular follow-up care, in case the cancer starts to grow.
If you have a larger cancer in the kidney, surgery is usually the first best treatment. Surgery to remove kidney cancers is performed by a specialist surgeon called a Urologist or Urooncologist (a Urologist who specialises in cancer). Surgery may either remove just a part of the kidney (called a “partial nephrectomy”) or the entire kidney, which is called a “radical nephrectomy”. Surgery might need to be done with a large incision (an “open” nephrectomy) or might be able to be done by keyhole surgery (a “laparoscopic” nephrectomy) which results in a shorter hospital stay and quicker recovery.
If the cancer is small (stage 1, <7cm) a “partial” nephrectomy may be possible, where the remaining normal kidney can be spared. If the cancer is larger (stage 2), or has started to spread near the kidney (stage 3) then the whole kidney is removed. Non-surgical approaches In some people an operation is not possible due to their age or other medical problems. It may be still possible to treat a localised kidney cancer without surgery, using other treatments. These include:
Radiofrequency ablation (RFA): where a needle containing a microwave antenna is inserted into the cancer under local anaesthetic, and the cancer is “cooked” from the inside.
Cryoablation: where a series of probes are inserted into the cancer, and then cooled with liquid nitrogen to freeze the cancer cells. This has a similar effect as RFA but may require a general anaesthetic.
Stereotactic body radiation therapy (SBRT): this newer, computer-controlled radiation has been tested in kidney cancer and many other cancers. SBRT gives lots of very small doses of radiation from a lot of different angles, such that a therapeutic dose of radiation lands on the cancer, but the normal organs and tissues around the cancer are only slightly affected.
Approaches to rare kidney cancers
If you have one of the inherited types of kidney cancer, it is possible you may get more kidney tumours in the future. Because of this, your surgeon might suggest a different approach for you. Patients with inherited types of kidney cancer need a long-term strategy and so should be seen by an expert in kidney cancer whenever possible.
Is there any treatment I can take to help ensure that the cancer won’t come back?
In many cancers, people can take additional “insurance policy” treatments to reduce the chance of the cancer coming back. You may have heard of chemotherapy, hormone therapy or radiotherapy as additional (“adjuvant”) treatments for cancer. Past studies indicated that these treatments did not seem to work for patients with kidney cancer. However one study published in 2017 showed benefit for select high-risk patients who took sunitinib for one year. Ongoing study of real-world data will help to determine which patients could benefit from taking sunitinib following surgery and how this approach affects their quality of life and overall survival. In the meantime, patients are encouraged to seek an expert opinion to make a fully informed decision.
Researchers are continuing to study immune therapy as an adjuvant treatment in kidney cancer.
Follow-up after treatment?
All cancer survivors should have follow-up care. Once you have finished your cancer treatment, you will establish a follow-up cancer care plan with your treatment team, which may include seeing a range of health professionals.
In general, kidney cancer survivors usually return to their specialist every three to four months during the first few years after treatment, and once or twice a year after that. At these visits, your doctor will look for side effects from treatment and will check to ensure you cancer has not returned (recurred) or spread (metastasised) to another part of your body. The type of tests will depend upon your stage and grade of kidney cancer. Like most cancers, the chance of the cancer returning is highest soon after treatment. The longer away from the treatment, the more chance the cancer will not recur. However, your treatment team will want to follow you for some time. In some countries, kidney cancer patients are followed for 5 years following initial surgery. Your patient organisation can refer you to guidelines for follow-up that are specific to kidney cancer in your country or other countries.