Treatments for Renal Cell Cancer (RCC)

• What is kidney cancer?
• Treatments
• Localised (Stages I–III) disease
• Advanced (Stage IV) disease
• Systemic treatments for metastatic clear cell RCC

What is kidney cancer?

Kidney cancer (renal cell cancer or RCC) accounts for 2–3% of all adult cancers and is the 7^th and 9^th most common cancer in men and women respectively. It is estimated that 209,000 new cases and 102,000 deaths due to all RCCs occur annually worldwide. RCCs can emerge spontaneously or may be associated with other diseases, such as the hereditary renal cancer syndromes. The overall incidence of renal cell cancer is rising, which is at least partially attributable to increased incidental detection due to widespread use of abdominal imaging technologies, such as CT and magnetic resonance imaging (MRI).

For more information about the different types of RCC and how they are differentiated, see RCC Subtypes.

 
To determine the degree of RCC advancement, cancers are staged using the TNM staging system. Stages I to III refer to localised disease and stage IV refers to advanced disease. 5-year survival rates for individuals with RCC are 96% for stage I disease, 82% for stage II, 64% for stage III and 23% for stage IV disease.

Treatments

Available treatments for kidney cancer depend on the degree of advancement. Localised RCCs (confined to the kidney) can be cured with surgery; however, surgery for metastatic clear cell RCC cannot cure RCC but still offers some survival benefit. Surgical options for RCC include:

• Nephron-sparing surgery or partial nephrectomy (where only part of the kidney is removed);
• Radical nephrectomy (entire kidney is removed); or
• Thermal ablation (destroying the cancer cells by applying concentrated heat).

Surgery for RCC aims to remove as much of the cancer as possible while preserving as much kidney function as possible. Even in metastatic (spread to other parts of the body) disease, total or partial removal of a primary tumour or deposits may still improve survival. Performing a partial nephrectomy is usually possible if metastatic tumours are less than 4 cm in diameter.
Medical therapies for RCC are generally only used in metastatic or advanced disease, or where surgery is not possible. These include conventional cancer therapies such as interferon alpha (IFN-alpha) therapy and IL-2 therapy. Advanced RCC can also be effectively treated with relatively new types of drugs, such as:

• Multiple receptor tyrosine kinase (rtk) inhibitors, such as sunitinib (e.g. Sutent), sorafenib (e.g. Nexavar) and pazopanib (e.g. Votrient);
• Mammalian target of rapamycin (mTOR) inhibitors, such as everolimus (e.g. Afinitor) and temsirolimus (e.g. Torisel); and
• Monoclonal antibody therapies, such as bevacizumab (e.g. Avastin).

Localised (Stages I–III) disease

Given early stage tumours are small and localised, surgery by partial nephrectomy is generally recommended. If a tumour cannot be removed by surgery, a radical nephrectomy (total removal of the kidney) is appropriate. If other significant illnesses are also present, surgery may not be able to be performed. Those tumours treated with thermal ablation have an increased likelihood of local recurrence (growing back in the same location) but may be useful for those people who cannot undergo surgery.
In Stage II and III disease, partial nephrectomy is generally not suitable and curative radical nephrectomy is preferred. If the tumour extends into nearby blood vessels, a radical nephrectomy is essential and clots may have formed within the vessels that also require removal.
20–30% of individuals with localised disease will relapse (the tumour will regrow), most of which occur within 3 years. Scientific research has demonstrated no advantage in the use of medications or radiotherapy after surgery for localised RCC disease.

Advanced (Stage IV) disease

Individuals with stage IV disease may benefit from surgery despite the degree of metastasis. Removing some of the tumour (cytoreductive nephrectomy) before drug therapy has also been shown to improve survival in some people.
The use of drug therapies for advanced RCC disease has been effective. This includes the use of drugs such as multiple receptor tyrosine kinase (rtk) inhibitors (sunitinib, sorafenib and pazopanib), mammalian target of rapamycin (mTOR) inhibitors (temsirolimus and everolimus) and monoclonal antibody therapies (bevacizumab).

Systemic treatments for metastatic clear cell RCC

Guidelines for the treatment of kidney cancer recommend the use of these drugs as first-line therapy for metastatic RCC disease. In the event of that one of these therapies doesn’t work, an alternate drug can be given.

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