Treatment of Kidney Cancer by Stage

The type of treatment(s) your doctors recommend will depend mainly on the stage of the kidney cancer and on your overall health and decisions. Other factors, such as type and grade of the cancer, might also affect your treatment options.

This section sums up the options usually considered for each stage of renal cell carcinoma (RCC), the most common type of kidney cancer.

Treating stage I or II kidney cancer

Stage I and II cancers are still only in the kidney.

Active surveillance

Some small (stage I) cancers might not need to be treated right away. Small tumors often grow slowly, and some might never cause serious problems. Because of this, active surveillance might be an option for some people with small kidney tumors. With this approach, the tumor is watched closely with regular imaging tests (such as CT scans or ultrasounds) and possibly other tests, and it’s only treated if it grows or starts to show other concerning signs.

Surgery

If treatment is needed, these cancers are usually removed with surgery when possible.

• Partial nephrectomy (removing the part of the kidney containing the cancer) is often the treatment of choice for smaller tumors. This is especially true for people have reduced kidney function (or who might have it in the future).
• Radical nephrectomy (removing the entire kidney) is often favored if the tumor is larger, if it’s in the central part of the kidney, or if there’s more than one tumor in the kidney.

Some lymph nodes near the kidney are often removed as well. More lymph nodes might need to be removed if any of them look enlarged on imaging tests, or if there’s a higher risk that the cancer might spread to the nodes.

Most often, no further treatment is needed after surgery.

If, after surgery, the cancer cells are found to have troubling features when evaluated in the lab (such as being very high grade), one option might be to get adjuvant (additional) treatment to help lower the risk of the cancer coming back. Most often this is with the immunotherapy drug pembrolizumab (Keytruda), which is given for about a year.

Other treatment options

For people who aren’t healthy enough to have surgery or who don't want surgery, other local treatments such as cryotherapy or radiofrequency ablation (RFA) can sometimes be used to destroy (ablate) the kidney tumor. Radiation therapy  (particularly stereotactic body radiation therapy, or SBRT) may be another option. Although these types of treatments can have outcomes similar to surgery as far as the chances of the cancer spreading to other parts of the body, some studies show the cancer might be more likely to come back in the same area.

Treating stage III kidney cancer

Stage III cancers have grown into nearby large veins or tissues around the kidney, and/or they have spread to nearby lymph nodes.

Surgery

Surgery is typically the main treatment for these cancers. Most often, this is a radical nephrectomy, in which the entire kidney is removed. A partial nephrectomy (removing the part of the kidney containing the tumor) might also be an option if it’s possible, especially in people with reduced kidney function or who have tumors in both kidneys.

Some lymph nodes near the kidney are often removed as well. More lymph nodes might need to be removed if any of them look enlarged on imaging tests, or if there’s a higher risk that the cancer might spread to the nodes.

If the cancer has grown into the inferior vena cava (the large vein that brings blood from the lower part of the body back up to the heart), your surgeon may need to cut open this vein to remove all of the cancer. This may require putting you on bypass (a heart-lung machine), so that the heart can be stopped for a short time to remove the cancer from the vein.

For clear cell RCC, an option after surgery is to get adjuvant (additional) treatment to help lower the risk of the cancer coming back. Most often this is with the immunotherapy drug pembrolizumab (Keytruda), which is given for about a year.

Other treatment options

For people who can’t have surgery for some reason, radiation therapy or another type of local treatment might be options.

Some stage III cancers can’t be removed completely by surgery or destroyed with other treatments. These cancers might get the same treatment as stage IV cancers (see below), with targeted therapy drugs, immunotherapy, or a combination of these.

Treating stage IV kidney cancer

In stage IV kidney cancer, the main tumor has grown outside the kidney, or the cancer has spread to other parts of the body such as distant lymph nodes or other organs.

Treatment of stage IV kidney cancer depends mainly on how extensive the cancer is and on a person’s general health.

For most people with stage IV kidney cancer, medicines such as immunotherapy and targeted drugs are the main treatments (see below). But in some cases, surgery may still be a part of treatment.

If both the kidney tumor and metastases appear to be removable

While it’s not common, sometimes the main tumor appears to be removable and there is only limited spread to another area (such as to one or a few spots in the lungs). In these situations, surgery to remove both the kidney and the metastasis (the outside area of cancer spread) may be an option if a person is in good enough health. Other options to treat the metastatic tumors might include ablative treatments or radiation therapy.

If all of the tumors are removed (or destroyed), additional (adjuvant) treatment with the immunotherapy drug pembrolizumab might be considered. It is typically given for about a year.

If just the kidney tumor appears to be removable

If the kidney tumor can be removed but the cancer has spread extensively elsewhere, treatment options might include:

• Removing kidney with the tumor first. This type of surgery (known as a cytoreductive nephrectomy) isn’t recommended for most people, but it might be an option for otherwise healthy people in a low-risk group . Surgery is then followed by drug treatments (immunotherapy and or targeted drugs ) for most people.
• Giving drug treatments (immunotherapy and/or targeted drugs) first. This is likely to be preferred for most people, even if it looks like the cancer in the kidney can be removed. For some people, if the cancer shrinks a lot with this treatment, surgery, ablative treatments, or radiation therapy  might be options to try to remove or destroy any remaining tumors.

If the kidney tumor isn’t removable

If the kidney tumor can’t be removed, the first treatment is usually with medicines such as immunotherapy and/or targeted therapy drugs. Often, one of each type of drug is part of the first treatment. Which ones are used depends to some extent on if the cancer is a clear cell RCC or a non-clear cell RCC. If one treatment doesn’t work (or stops working), another one can often be tried.

For some less common types of non-clear cell RCC, such as collecting duct RCC or renal medullary carcinoma, chemotherapy is often the first treatment.

While it’s not common, sometimes the first treatment might shrink the tumors enough so that surgery, ablative treatments, or radiation,  might be options to try to get rid of any remaining tumors.

In other situations, surgery or other treatments might be used to help relieve symptoms from the cancer, such as pain or bleeding, rather than trying to get rid of the cancer completely. This type of treatment is called palliative therapy. (You can read more about palliative treatment for cancer in Palliative (Supportive) Care or in Advanced Cancer, Metastatic Cancer, and Bone Metastasis.) If you have advanced kidney cancer and your doctor suggests surgery, ablation, or radiation, be sure you understand what the goal of the treatment is.

No matter what type of treatment you’re getting, having your pain controlled can help you maintain your quality of life. Treating the cancer itself can often help with this. Medicines to relieve pain can also be helpful, and they will not interfere with your other treatments. Controlling any pain you have can often help you be more active and continue your daily activities.

Because advanced kidney cancer is very hard to cure, clinical trials of new combinations of targeted therapy drugs, immunotherapy, or other new treatments are also options.

Treating recurrent kidney cancer

Cancer is called recurrent when it comes back after treatment. Recurrence can be local (near the area of the original tumor), or it may be in distant parts of the body.

Treatment of kidney cancer that comes back (recurs) after initial treatment depends on where it recurs and what treatments have been used, as well as a person’s health and wishes for further treatment.

Local recurrence

For cancers that recur near the area of the original kidney tumor after surgery, further surgery or other localized treatments or radiation might be options. Even if not all of the cancer can be removed or destroyed, these treatments might still help relieve symptoms in some people. Other treatment options will most likely include immunotherapy and/ortargeted therapy drugs. Clinical trials of new treatments are an option as well.

Distant recurrence

Kidney cancer that recurs in distant parts of the body is treated like stage IV cancer (see above). Your options will depend on where the cancer is; if it’s thought to be removable or not; which, if any, drugs you received as part of your first treatment (and how long ago you got them); and on your overall health and preferences.

For cancers that continue to grow or spread during treatment with immunotherapy or targeted therapy drugs, different drugs still might be helpful. Recurrent cancers can sometimes be hard to treat, so you might also want to ask your doctor about clinical trials.

For some people with recurrent kidney cancer, palliative treatments may be the best option. These treatments are intended to help control the cancer and relieve any symptoms it is causing. Options might include radiation therapy, ablative treatments, or even some type of surgery, if a person is healthy enough. Controlling symptoms such as pain is also an important part of treatment at any stage of the disease.

For more information, see Understanding Recurrence.