Treatments for stage 4 kidney cancer

The following are treatment options for stage 4 kidney cancer. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.

Targeted therapy is the main treatment for stage 4 kidney cancer. Targeted therapy uses drugs to target specific molecules (such as proteins) on cancer cells or inside them. These molecules help send signals that tell cells to grow or divide. By targeting these molecules, the drugs stop the growth and spread of cancer cells and limit harm to normal cells.

Your healthcare team will consider many disease-related and prognostic factors (predictors of survival) to help them decide which targeted therapy would be the most effective for you. These factors include the type of kidney cancer and any other treatments you’ve already had, as well as the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) classification.

Vascular endothelial growth factor (VEGF) is one of the main proteins that help to build a blood supply, which a small tumour needs to grow larger. Targeted therapy drugs that work on VEGF to treat stage 4 kidney cancer include:

• sunitinib (Sutent)
• pazopanib (Votrient)
• sorafenib (Nexavar)
• cabozantinib (Cabometyx) (may not be covered by all provincial health plans)
• axitinib (Inlyta)

Sunitinib is usually the first drug to be used because it has been shown to be the most effective. It can also be combined with gemcitabine (Gemzar), a chemotherapy drug, for kidney cancers that aren’t a clear cell type or for kidney cancer with poor prognostic factors.

Mammalian target of rapamycin (mTOR) is a protein that helps cells grow and divide. Targeted therapy drugs that work on mTOR to treat stage 4 kidney cancer include:

• temsirolimus (Torisel)
• everolimus (Afinitor)

Tyrosine kinase is a protein on the surface of cells that sends signals to help cells grow and form new blood vessels. A targeted therapy drug that works on tyrosine kinase (called a tyrosine kinase inhibitor) to treat stage 4 kidney cancer is lenvatinib (Lenvima). It may be used in combination with everolimus if you have been given VEGF targeted therapy before. Lenvatinib may not be covered by all provincial health plans.

You may be offered surgery before you start targeted therapy. The surgeon will remove the kidney with the tumour and as much of the cancer as possible. This surgery is called a cytoreductive nephrectomy. It may improve how well you respond to targeted therapy.

If kidney cancer spreads to the brain or lungs, surgery is sometimes used to treat it. Find out more about brain metastases or lung metastases.

Immunotherapy helps to strengthen or restore the immune system’s ability to find and destroy cancer cells. It is not usually used in Canada because targeted therapies are better at treating kidney cancer.

Immunotherapy may be used in specialized centres to treat people who have kidney cancer, either as a main treatment in certain cases or for kidney cancer that no longer responds to targeted therapy. Your healthcare team may recommend immunotherapy as a good treatment option for you. Immunotherapy drugs used to treat stage 4 kidney cancer includes:

• Nivolumab (Opdivo) may be offered if the kidney cancer is no longer responding to a VEGF targeted therapy drug.
• A combination of nivolumab and ipilimumab (Yervoy) may also be offered for people who have IMDC intermediate and poor risk classification.
• Nivolumab may be combined with a targeted therapy drug called cabozantinib (Cabometyx) to treat advanced kidney cancer that cannot be treated with surgery or radiation therapy or for kidney cancer that has spread (called metastatic kidney cancer).
• Pembrolizumab (Keytruda) may be used treat advanced or metastatic kidney cancer that hasn't been treated with systemic therapy. It is given along with the targeted therapy drug axitinib.
• High-dose intravenous interleukin-2 (aldesleukin, Proleukin) is the most common cytokine drug used. It can cause serious side effects, so it must only be given at cancer centres that have experience giving this treatment. High-dose interleukin-2 is only given to people who are healthy enough to tolerate the side effects and is rarely used.

Arterial embolization blocks the blood supply to a kidney tumour. It can help shrink the tumour, control bleeding in the kidney and relieve symptoms such as pain. You may be offered arterial embolization if you aren’t well enough to have targeted therapy or surgery.

Ablation therapy uses heat or cold to destroy the kidney tumour. You may be offered ablation therapy if you can’t have targeted therapy or you aren’t well enough to have surgery.

If you aren’t well enough to have targeted therapy, you may be offered external radiation therapy. This treatment can help relieve pain, bleeding and other symptoms.

If kidney cancer spreads to the bones or brain, radiation therapy is often used to treat it. Find out more about bone metastases and brain metastases.

Active surveillance can be an option if you are not well enough to have surgery or if you don’t have any symptoms. Your doctor will watch the cancer closely rather than giving treatment right away. It involves regular visits with the doctor where you may have a physical exam, blood tests and imaging tests to see if the cancer has progressed.

You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.

Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.

Talk to your doctor about clinical trials open to people with kidney cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.