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KIDNEY CANCER
( By JASCAP )

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Treating kidney cancer

Treatment for kidney cancer

Surgery is the main treatment for cancer of the kidney. If all of the cancer can't be removed by surgery, other treatments may be used. These may include biological treatments, or targeted treatments. Occasionally chemotherapy, radiotherapy or hormonal treatment is used. In rare cases, cancer of the kidney will spontaneously improve without any treatment, but this is not usual.

Your doctors will plan your treatment by taking into account a number of factors, including your age and general health, the type and size of the tumour and whether it has spread.

How treatment is planned

In most hospitals, a team of specialists will meet to discuss and agree on the plan of treatment they feel is best for your situation. This multidisciplinary team (MDT) will normally include:

  • a urologist (a surgeon who specialises in treating kidney cancers)
  • an oncologist (a specialist in cancer treatments such as chemotherapy, radiotherapy and biological therapy)
  • a nurse specialist, who gives information and support
  • a radiologist, who helps to analyse scans and x-rays
  • a pathologist, who advises on the type and extent of the cancer.

Other staff are also available to help you if necessary, such as

  • dietitians
  • physiotherapists
  • occupational therapists
  • psychologists and counsellors.

Your doctor will discuss with you what the best treatment is for your particular situation or they may offer you a choice of treatments. If you have to decide between treatments, make sure that you have enough information about each treatment option, so that you can decide which is right for you. You may find it helps to ask questions about what is involved with each treatment and the possible side effects they may cause.

If you have any questions about your treatment, don't be afraid to ask your doctor or the nurse looking after you.

It often helps to make a list of the questions you want to ask and to take a close friend or relative with you to help you remember what is discussed.

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment.

No medical treatment can be given without your consent, and before you are asked to sign the form you should have been given full information about:

  • the type and extent of the treatment you are advised to have
  • the advantages and disadvantages of the treatment
  • any possible other treatments that may be available
  • any significant risks or side effects of the treatment.

If you do not understand what you have been told, let the staff know straight away so that they can explain again. Some cancer treatments are complex, so it is not unusual for people to need repeated explanations.

It is often a good idea to have a friend or relative with you when the treatment is explained, to help you remember the discussion more fully. You may also find it useful to write down a list of questions before you go to your appointment.

Patients often feel that the hospital staff are too busy to answer their questions, but it is important for you to be aware of how the treatment is likely to affect you. The staff should be willing to make time for you to ask questions.

You can always ask for more time to decide about the treatment if you feel that you can't make a decision when it is first explained to you.

You are also free to choose not to have the treatment. If you are considering not having treatment it is essential to discuss this fully with your cancer specialist. The staff can explain what may happen if you do not have it. It is essential to tell a doctor, or the nurse in charge, so that they can record your decision in your medical notes. You do not have to give a reason for not wanting to have treatment, but it can be helpful to let the staff know your concerns so that they can give you the best advice.

Benefits and disadvantages of treatment

You may feel worried at the thought of having cancer treatment, because of the potential side effects that can occur. In this situation it is often helpful to get more information about what can be done to prevent or control side effects. The doctor who will be giving you the treatment will be able to answer your questions about this.

Treatment can be given for different reasons and the potential benefits will vary depending upon the individual situation.

Early-stage kidney cancer

In people with early-stage kidney cancer, surgery is usually done with the aim of curing the cancer. Occasionally, additional treatments are given to help reduce the risks of it coming back.

Advanced-stage kidney cancer

If the cancer is at a more advanced stage, treatment may only be able to control it. This may help you to live for longer or it may reduce your symptoms and improve your quality of life. However, for some people the treatment will have very little effect upon the cancer and they will get the side effects without any of the benefits. If you are having treatments you will be monitored closely for signs that it is working. This is so that treatment can be stopped if it isn't helping you and is only causing side effects.

Treatment decisions

If you have been offered treatment with the aim of curing your cancer, the decision whether to accept it may not be a difficult one. But, if a cure isn't possible and the treatment is being given to control the cancer for a period of time, it may be more difficult to decide whether to go ahead with treatment or not.

Making decisions about treatment in these circumstances is always difficult, and you may need to discuss things in detail with your doctor. If you choose not to have treatment for the cancer, you can still be given treatment to control any symptoms you may have. Treatment given in this situation is known as supportive care or palliative care.

Second opinion

Even though a number of cancer specialists work together as part of a team to decide on the most suitable treatment for you, you may want to have another medical opinion. Most doctors will be willing to refer you to another specialist for a second opinion if you feel that it will be helpful. This can take time to organise and may cause a delay in the start of your treatment, so you and your doctor need to be confident that it will give useful information.

If you go for a second opinion, it may be a good idea to take someone with you, and to have a list of questions ready so that you can make sure your concerns are covered during the discussion.

Surgery for kidney cancer

Surgery is often the only treatment that is needed. The most appropriate type of surgery for your situation will depend on the size of the cancer and whether or not it has spread, as well as your age and general health. It is important to discuss any operation fully with your surgeon before you have it.

Nephrectomy (removal of the kidney)

The most common type of surgery for kidney cancer is a nephrectomy. The surgeon removes all of the affected kidney and some surrounding tissue. This operation usually involves a cut (incision) made between the lower ribs on the side of the tumour. The surgeon may also remove some, or all, of the lymph nodes close to the kidney to check whether they contain cancer.

It is possible to live a completely normal life with just one kidney; it will do the work usually shared by two kidneys. But, removing a kidney is a big operation and so you need to be reasonably fit. This means that this type of surgery isn't suitable for everyone. In some cases people who aren't fit enough to have standard surgery may be able to have an operation using one of the newer surgical techniques that are being developed, such as keyhole surgery.

Partial nephrectomy

Instead of taking out all of the kidney, the surgeon will sometimes only remove the tumour and the part of the kidney surrounding it. This is called a partial nephrectomy or nephron-sparing surgery and it is usually only possible if the tumour is smaller than 4cm.

A partial nephrectomy may also be used if it is important to try to keep the affected kidney, for example if you have only one kidney or have kidney disease. It may also be used if you have an inherited form of kidney cancer that increases your risk of cancer developing in the other kidney.

Keyhole surgery

In some situations, it may be possible to have keyhole or laparoscopic surgery to remove some, or all of your kidney. In this type of surgery only small openings are made instead of one larger cut (incision). The surgeon uses a special instrument called a laparoscope to see and work inside the belly (abdomen).

The laparoscope is a thin tube with an eyepiece at one end and a light and a magnifying lens at the other. It is put into the abdomen through a small cut in the skin. Generally about three small cuts and one larger cut are needed for the operation. The larger cut is usually made close to the belly button and is used to remove the kidney.

The main advantage of this type of surgery is that it leaves a much smaller wound and so has a shorter recovery time. Keyhole surgery may be used for some people, who would not have been fit enough to have an operation otherwise.

The chances of curing kidney cancer appear to be as good with keyhole surgery as with bigger operations.

However, the techniques haven't been used for long enough to be absolutely sure of this.

Keyhole surgery should be carried out by surgeons with specialist training and experience in using laparoscopic techniques. So, if it is suitable for you, and you choose to have this type of surgery, you may need to travel to another hospital to have the operation.

Surgery when the cancer has spread

Secondary tumours (or metastases) can develop if cancer cells break away from the original tumour (the primary) and travel in the bloodstream or the lymphatic system. The cells may settle and begin to grow in a different part of the body, forming a new tumour.

If the cancer has already spread to other places in the body (metastatic or secondary cancer) it may still be worth having the kidney with the cancer removed. If the tumour in the kidney is causing symptoms such as pain or bleeding, or if it is affecting the balance of chemicals in your blood, taking it out may relieve this.

Although this operation will not usually be able to cure the cancer, it may help other treatments to work better and so may help you to live for longer. However, these possible advantages need to be weighed up against the effects of having a major operation. Deciding whether to go ahead with an operation in these circumstances can be very difficult. It is important that you discuss the advantages and disadvantages with your doctors when making up your mind.

Rarely, surgery may be used to remove small secondary tumours in another part of the body. This is very specialised surgery. It is generally only possible if the cancer has spread to a limited area usually just to one place in the body. It is also important that you are fit and healthy enough to cope with the operation. Removing a secondary cancer may help to slow down and control the cancer for longer. Occasionally it may be used to try to cure the cancer.

Embolisation

If surgery to remove the kidney isn't possible because of your general health or because the tumour is too large, it may be possible to block off the blood supply to the tumour. This is called embolisation. A thin plastic tube (catheter) is put into a blood vessel in your groin. Then, using x-ray pictures as a guide, the surgeon threads the catheter upwards until the tip is in the artery that carries blood to the kidney. A substance is then injected through the catheter into the kidney. This will block the blood supply to the kidney and so cut off the supply of oxygen and nutrients to the tumour.

Embolisation is usually done to try to shrink the tumour and to help control symptoms such as bleeding.

After your operation

After your operation you will be encouraged to start moving about as soon as possible. This is an essential part of your recovery. If you have to stay in bed, the nurses will encourage you to do regular leg movements and deep- breathing exercises.

When you get back to the ward you will have a drip of fluid and salts going into your vein until you are able to eat and drink normally. You will probably have drainage tubes from the wound to stop any excess fluid collecting, and so help the wound to heal. The tubes will only be needed for a short time and will be taken out before you go home.

Usually you will have a small tube (catheter) draining urine from your bladder into a collecting bag. This will save you having to get up to pass urine. The catheter is usually removed after a couple of days.

You will be given painkilling drugs regularly, to control any pain. If you still have pain, it is important to let the ward nurse know. They can have the type or dose of painkillers changed to something that is more effective for you.

How long you need to stay in hospital after your operation will depend on the type of surgery you have had. The time can range from 410 days depending on the type of operation and on your general health and fitness. Many people like to know how soon they will be able to get back to doing normal things, like shopping, gardening, playing sport or going to work. This will vary depending on the surgery you have had and on you as a person. Your doctor or nurse will be able to advise you.

Before you leave hospital you will be given an appointment to attend an outpatient clinic for a check-up about six weeks after your surgery. This is a good time to discuss any problems you may have after your operation.

Radiotherapy for kidney cancer

Radiotherapy treats cancer by using high-energy x-rays, which destroy the cancer cells while doing as little harm as possible to normal cells. It is most often used to try to shrink the cancer if it is causing pain, or to treat cancer that has spread to the brain or the bones.

The treatment is given in the hospital radiotherapy department as an outpatient. Radiotherapy is often given in divided doses called fractions. When used to relieve symptoms, radiotherapy is usually given for a few minutes every day for a few days. Your doctor will discuss the treatment with you.

After positioning you will be left alone for a few minutes while treatment is given, but you can still talk to your radiographer via an intercom

Side effects

Radiotherapy can cause general side effects such as feeling sick (nausea), being sick (vomiting) and tiredness (fatigue). These effects are usually mild when the radiotherapy is given to relieve symptoms. The doctor who plans your radiotherapy (clinical oncologist) will be able to advise you about what to expect. Usually side effects disappear gradually once your course of treatment is over but it is important to let your doctor know if they continue.

Biological treatments for kidney cancer

Biological treatments work by encouraging the body's immune system to attack the cancer. They may be used to try to control locally advanced kidney cancer and kidney cancer that has spread to other parts of the body. For some people they may help to shrink the cancer or slow its growth.

Interferon alpha

Interferon is a type of immunotherapy for kidney cancer. It is a substance normally produced by the body to fight viral infections such as flu, but has a number of effects on the immune system. Interferon can be produced in the laboratory.

The type of interferon used to treat cancer of the kidney is called interferon alpha-2a (Roferon-A®). It is usually given three times a week by injection under the skin (subcutaneously). The injections may be slightly uncomfortable. You, or your relatives, can be taught to give the injections at home, and you can use either a pen- injection device or a pre-filled syringe, which makes it easier to do this. A free, home-nurse support service is available to help new patients with their first few injections. The nurses can also give advice on managing any side effects that may occur. Your GP, practice nurse or district nurse can also help if necessary.

In the first week or two of treatment, interferon often causes side effects similar to flu symptoms especially chills, a high temperature, headaches, and aching in the back, joints and muscles. You may also feel tired, sick, and lose your appetite. Although these symptoms are uncomfortable at the time, they tend to become less severe as the treatment continues.

Aldesleukin

Another biological treatment sometimes used for cancer of the kidney is aldesleukin (Proleukin®). This is an artificial version of a protein called interleukin-2 (IL-2) that occurs naturally in the body and stimulates a type of blood cell (lymphocytes) to fight infection.

Aldesleukin is either given as an injection under the skin or by drip into a vein (intravenously). It is usually only given in specialist cancer centres. The most common side effects of aldesleukin include: a high temperature; headaches; feeling sick and being sick (nausea and vomiting); weight gain; low blood pressure; skin rashes and itching; loss of appetite; and diarrhoea. These side effects can be upsetting but are temporary and will disappear when the treatment has finished. It is important to tell your doctor or nurse if your side effects are severe. They will be able to treat some of the side effects.

Doctors are looking at aldesleukin to see how useful it is in treating cancer of the kidney. If this treatment might be appropriate for you, your hospital specialist may be able to refer you to one of the hospitals carrying out trials.

Targeted treatments for kidney cancer

Newer targeted treatments such as, sunitinib and sorafenib, have recently been developed. These treatments may be helpful for people with locally advanced and metastatic kidney cancer (stages 3 and 4). They are used to try to control the cancer by shrinking it or by slowing its growth. As they are quite new these treatments may not be widely available.

The National Institute for Health and Clinical Excellence (NICE) is an independent organisation that gives advice on which new drugs and treatments should be available on the NHS. NICE has recently published guidance on the use of sunitinib for people with advanced renal cell cancer. It recommends that sunitinib can be used as a first choice treatment for people with advanced or metastatic renal cell cancer if:

  • they are able to have immunotherapy (such as interferon alpha) and
  • they are fit enough to have the treatment (for example, able to do light housework or office work).

NICE is currently looking at how other drugs such as sorafenib, bevacizumab and temsirolimus can best be used to treat people with renal cell cancer. Guidance is expected to be published later this year.

The Scottish equivalent to NICE, the Scottish Medicines Consortium (SMC), has said sunitinib and sorafenib should not be made available to treat kidney cancer on the NHS in Scotland. This advice may change in the future depending on NICE guidance.

Sunitinib (Sutent®) may be used to treat people with locally advanced kidney cancer (stage 3) or kidney cancer that has spread to other areas of the body (stage 4). It is a type of drug called a multi-targeted kinase inhibitor. It is taken daily as a tablet and interferes with signals that tell cancer cells to grow. It also works by slowing the growth of new blood vessels within the tumour. Common side effects of sunitinib include skin changes such as a rash, hair-thinning, raised blood pressure and tiredness.

Sorafenib (Nexavar®) may be used to treat people with stage 3 or stage 4 kidney cancer who are no longer being helped by treatment with interferon-alpha (IFN) or interleukin-2 (IL-2), or for whom these drugs are not suitable. It is a type of drug called a multikinase inhibitor and is taken daily as a tablet. It is designed to stop cancer cells from growing and to prevent the cancer from developing new blood vessels. Common side effects include diarrhoea, skin reactions, and tiredness.

Chemotherapy for kidney cancer

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It works by disrupting the growth and division of cancer cells. The drugs may be taken as tablets or capsules or by injection into a vein (intravenously).

Chemotherapy is not as good at treating kidney cancer as some other treatments such as biological treatments. But you may be offered chemotherapy as part of a trial of new drugs, or in combination with a biological treatment. Fluorouracil (5FU) is one of the most commonly used chemotherapy drugs for treating renal cell kidney cancer. It is usually given in combination with interferon and aldesleukin.

Common side effects of chemotherapy drugs can include feeling more tired than usual and a temporary increase in your risk of infection. Other side effects may include feeling sick (nausea), vomiting and hair loss. Your doctor or nurse will tell you what problems, if any, to expect from your treatment.

Hormonal treatment for kidney cancer

Some people may be given the hormone progesterone to take daily as tablets. Progesterone treatment usually causes few side effects.

Any side effects are usually mild and can include an increased appetite and putting on weight. This treatment may reduce your sex drive. Fluid retention may also occur and you may notice that your feet and ankles become swollen. If this is a problem for you, it can be treated with drugs called diuretics.

Newer treatments for kidney cancer

Many new treatments are being tested for kidney cancer. They may be given to try to reduce the risk of cancer coming back after surgery (called adjuvant treatment), or to try to control kidney cancer that has spread. Because these treatments are still experimental they will usually only be available within clinical trials. If your doctor thinks there is a clinical trial which may be helpful for you, they can refer you to a specialist hospital where the trial is being run. You may have to travel a long way to the specialist hospital.

Immunotherapy

TroVax® is a vaccine that is being tested as a treatment for advanced kidney cancer. It is being tested with three treatments that are already used to treat kidney cancer: interferon, aldesleukin, and sunitinib.

A number of other vaccines are also being tested in clinical trials to see if they can help to stimulate the immune system to destroy kidney cancer.

Targeted treatments

Bevacizumab (Avastin®) is a type of treatment known as a monoclonal antibody and is given as a drip into a vein (intravenous infusion). It is being researched as a treatment for people with stage 3 or 4 kidney cancer when given in combination with interferon or aldesleukin. It works by blocking a special type of protein that can encourage cancer cells to make a new blood supply. This may help to slow the growth of the cancer.

Temsirolimus (Torisel®) is given as a drip into a vein (intravenous infusion). It blocks the function of a special protein (mTOR) that is found inside cells. The protein has an important role in regulating cell growth and survival. In clinical trials, temsirolimus has been used as a treatment for people who have advanced kidney cancer which has a higher risk of growing or spreading more quickly.

There are several other targeted therapies currently being developed. These may target either the cancer's ability to make its own blood supply (called angiogenesis), or the way in which the cancer cells respond to signals that affect their numbers, growth, or survival. Your doctor or specialist nurse can give you further information about newer treatments.


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