Advanced Cancer

Advanced kidney cancer refers to kidney cancers that are growing outside of the kidney and spreading either by direct growth into veins outside of the kidney, lymph nodes or adjacent organs; or metastatic spread to organs away from the kidneys like the lungs, brain or bones.  In general, there are no curative treatments for metastatic kidney cancer, although a number of treatments and prolong life, improve quality of life, and offer a rare chance at cure.  Traditional chemotherapy and radiation therapy are not effective for the treatment of kidney cancer.  Therefore, surgery in combination with a variety of systemic therapies are used in patients with advanced kidney cancer.  

Cytoreductive nephrectomy refers to removal of the kidney and cancerous tumor in the setting of cancer spread around the body.  In metastatic kidney cancer, cytoreductive nephrectomy is not often curative but can prolong survival in suitable patients.

Metastatectomy refers to removal of metastatic sites of kidney cancer.  As there are no curative treatments for metastatic kidney cancer, patients with limited sites of metastatic disease may be eligible for surgical removal at the time of nephrectomy or after.  Possible sites include the adrenal glands, pancreas, liver, lung and bone.  These surgeries are often done in conjunction with other surgical teams including general surgical oncologist, thoracic surgeons or orthopedic surgeons.

Systemic therapies are most often prescribed by a medical oncologist and the major types of systemic therapy are discussed below:

  • Immunotherapy: Traditionally, medications like interferon-alpha and interleukin-2 (IL-2) were used to “boost” the immune system and fight off kidney cancers.  Interferon-alpha is no longer used as better agents now exist.  IL-2 offers a rare chance at cure (5-7%) but is an extremely toxic therapy. 
  • Targeted therapy: Kidney cancers can release a number of hormones, proteins and molecules that allow them to gain blood and nutrients from the body.  Targeted therapies block the action of many of these pathways, can shrink kidney tumors, and keep kidney cancer in check for a prolonged period of time.  Targeted therapies can be given by pill or intravenous infusion.  Some of the common targeted therapy agents are  Sorafenib (Nexavar),  Sunitinib (Sutent), and Pazopanib (Votrient), although many others exist.  
  • Checkpoint Inhibitors: Kidney cancers have evolved to turn off the body’s response through the immune system.  Checkpoint inhibitors effectively “turn on” the immune system, help the body recognize these cancers and fight them off.  Nivolumab (obdivo) is the currently the only FDA-approved checkpoint inhibitor for the treatment of kidney cancer.

Therapies can be given before or after surgery.  Patients with advanced kidney cancer should be familiar with the following terms regarding the timing of systemic therapies.

  • Adjuvant therapy: refers to treating a patient for metastatic cancer, even though that cancer cannot be seen.  This is often referred to as “micrometastatic disease.” Patients with very high-risk or aggressive cancers who are at the highest risk of cancer recurrence can consider adjuvant therapy. 
  • Neo-adjuvant therapy: similarly to adjuvant therapy, refers to treating a patient for metastatic cancer, even though that cancer cannot be seen.  However, neoadjuvant therapy is given prior to surgery rather than after.
  • Salvage therapy: refers to treating a patient with a visible local or distant recurrence of cancer. Local recurrence refers to cancer where the kidney used to be and distant recurrence refers to metastatic disease.