When diagnosed with “locally progressive, metastatic kidney cancer” – advanced kidney cancer, does it mean to give up treatment? No, it doesn’t. In fact, many patients can still survive well with a combination of treatments.
So what are the current treatment options for “advanced kidney cancer”?
I. Palliative surgery
Most people think that advanced kidney cancer is inoperable, but surgery is not a cure, but a palliative treatment.
What is palliative care? It means that even if the tumor cells have spread to other parts of the body, the primary lesion can still be removed (palliative or subtractive nephrectomy) to improve the outcome, and the patient still needs systemic therapy.
Removal of the primary lesion is particularly important for the treatment of metastatic kidney cancer for two reasons:
- Reducing the effects of the tumor on the body, such as pain, hormone production, and other symptoms of cachexia, has the potential to improve overall treatment outcomes;
- Go straight to the source of the tumor and remove the source of the tumor.
But for patients with large kidney cancer who are too ill to undergo surgery, the risks associated with surgery and postoperative recovery need to be considered, and surgery may not be recommended because your doctor may say to you, “Surgery may hasten death or you may die on the operating table.
The most appropriate candidate for tumor reduction surgery is someone who is in good general health, whose kidney can be safely removed, and who has most of the tumor load in the kidney. This is also a good way to remove the source of the tumor and to guide the next step of systemic therapy based on pathological findings. This is like a battle against bandits, where the head of the bandits (the primary focus) is knocked out, and then the minions underneath surrender or flee, which can limit and delay the development of the tumor to some extent.
II. Drug therapy
Drug therapy for advanced kidney cancer, many patients’ impressions are stuck on the use of chemotherapy drugs and their severe side effects such as hair loss, nausea and vomiting. Since the launch of targeted drugs, the treatment of advanced kidney cancer has achieved more satisfactory results, but it does not achieve 100% efficacy. In general, some patients’ tumors will gradually shrink and fade away; some patients’ tumors will maintain a stable state and stop growing, and patients will “live with the tumor”. The main options for patients with advanced kidney cancer are targeted therapies, such as sorafenib and sunitinib.
Targeted therapies work in a completely different way than chemotherapy. The chemotherapy drugs kill tumor cells by interfering with the biological cycle of the cells, and it is difficult for normal human cells not to be affected; however, the targeted drugs, especially the commonly used tyrosine kinase inhibitor (TKI), work by controlling the growth of the tumor rather than killing it directly, so they are more targeted and targeted.
At the same time, targeted therapies target the characteristics of kidney cancer (kidney tumors are a class of tumors rich in blood vessels, and their growth and metastasis are closely related to blood vessels), blocking the tumor angiogenesis pathway, and without the new blood vessels, the tumor cells are deprived of nutrient supply. Therefore, targeted therapy can inhibit the continued progression and metastasis of the tumor.
But the use of targeted drugs also has the following problems:
Drug side effects
This aspect is also one of the most frightening and difficult for patients to adhere to the medication. The side effects of targeted drugs are almost the same, such as high blood pressure, skin loss on hands and feet, and mouth ulcers. But overall, most of the adverse reactions to targeted drugs are tolerable and not very life-threatening, and some of the slightly more severe reactions can be controlled by adjusting the drug dose and treating symptoms.
What should I do if I fail targeted therapy?
The reason why malignant tumors are “malignant” is that if a pathway is blocked during the growth of these tumors, it will bypass that pathway and reach its goal from another direction. The most important thing is that the patient will be able to use the targeted drug for a period of time and will almost always develop what is called drug resistance, which is clinically called drug failure.
At the very beginning of the drug, the tumor growth will stall, shrink, or even disappear, but after a period of time on the drug, the tumor starts to grow again or new metastases appear and get out of control, and that’s when you have to consider changing the drug. The first-line drugs are called first-line drugs, and when the first-line drugs fail, the drug is changed to second-line treatment. The second line will also fail, and so on, then you can switch to the third line again, and later there may also be four, five or even more lines, through more and more types of drugs to control tumor growth.
But with all of the drug regimens, the idea is the same: to make advanced cancer a chronic disease, where the tumor can be controlled and the patient can live longer, even though it’s constantly changing drugs.
The introduction of a new immunotherapy drug, Nivolumab, in 2014 may bring more options for kidney cancer patients. It was approved by the FDA in November 2015 for use in patients with advanced renal cell carcinoma who had previously received anti-angiogenic therapy.
Preliminary studies in small samples have confirmed the efficacy of PD-1 monoclonal antibody in combination with TKI drugs, with objective efficacy rates of 60% to 70% and median progression-free survival times of 17 to 21 months, whether in combination with axitinib, bevacizumab, or lenvatinib, with efficacy data much better than current first-line therapy; however, the side effects of PD-1 monoclonal antibody in combination with CTLA-4 monoclonal antibody (ibritumomab) The relatively high number of side effects associated with combination therapy limits its clinical use.
Immunotherapy, represented by Nivolumab, could be a new hope for a cure for kidney cancer patients. The past decade was indeed the era of targeted therapy for advanced kidney cancer, and now the advent of immunotherapy means that targeted therapy is no longer a monopoly, and immune-targeted combinations will gradually become mainstream.