Not All Patients With Advanced Kidney Cancer Need Surgery

New research suggests some late stage patients can be treated with systemic therapy, alone.

The results of a newly published study suggest that not all patients with late stage metastatic kidney cancer (cancer spread) need surgery. The alternative treatment? Targeted systemic therapy with Tyrosine kinase inhibitors, alone.

“Based on clinical trials published in early 2000s, the standard of care has been to remove the kidney surgically for late-stage metastatic kidney cancer patients,” says Dr. Chad Ritch, an expert in kidney cancer at the University of Miami Health System.

“Tyrosine kinase inhibitor drugs, such as sunitinib (Sutent®), are often prescribed to treat metastatic cancer and limit the chance of further spread. But adding surgery can potentially pose further health risks, pain, blood loss, blood clots and infections.”

A recent study, the CARMENA trial, published in the August issue of the New England Journal of Medicine, showed surprising news: intermediate and high risk (based on specific criteria) metastatic kidney cancer patients treated with sunitinib alone, did no worse than those treated with both surgery and sunitinib combined.

Patients treated with sunitinib, alone, had a median overall survival of 18.4 months compared to 13.9 months for similar patients who received the drug after a kidney was removed surgically.

“The main finding,” says Dr. Ritch, “is that those patients with aggressive metastatic cancer, depending on their risk group, probably do not get much benefit from adding surgery to systemic therapy.

For several years, we have already been using a technique called risk stratification to help determine which kidney cancer patients may benefit from surgery. We look at age, other health conditions and additional factors in patients’ blood work to ensure that they would be helped with surgery.”

He cautions patients not jump to the conclusion that all advanced patients may now avoid surgery.

“Those enrolled in the study had very advanced and aggressive cancers. Some patients with less aggressive metastatic cancers may still benefit from surgery,” added Dr. Ritch. “Additional research will see if individuals with less advanced metastatic renal cell cancers will have a similar benefit. Other Tyrosinse kinase inhibitor drugs may be tested in the future to see if one works well in combination with surgery. The goal is to minimize harm to patients and maintain treatment benefit.”

Further research is needed to determine if systemic therapy alone is going to become the standard of care for everyone and whether clinical treatment guidelines will be amended.

Meanwhile, treatments are improving for localized (i.e. non-metastatic) kidney cancer patients. The American Urological Association (AUA) just updated its clinical guidelines for the treatment of patients with localized benign and malignant renal masses. The AUA is now incorporating use of a renal mass biopsy more frequently in certain patients.

“Over the past 20 years, scans and imaging studies are used more often and we are picking up more small, incidental tumors,” explained Dr. Ritch. “Not all tumors need to be treated and some can be managed with a biopsy and active surveillance (watchful waiting).”

Another approach is partial removal of the tumor instead of the entire kidney, he offered. Partial nephrectomy, or kidney-sparing surgery, has become more commonplace with the advent of robotic-assisted surgical systems and expertise. Research has shown that the robotic approach facilitates less blood loss, shorter hospital stays and faster recovery for these patients with small kidney tumors, while keeping most of the functional kidney.

“The CARMENA research findings, combined with new diagnostic recommendations and surgical approaches all point toward better potential outcomes for more patients than ever before,” added Dr. Ritch. 

John Senall is a contributing writer for UMiami Health News. He is a former hospital and comprehensive cancer center communications director.

Tags: CARMENA, Dr. Chad Ritch, kidney cancer, Sylvester Comprehensive Cancer Center