Demystifying Kidney Cancer : Key Webinar takeaways

Renal cell carcinoma is the most common type of adult kidney cancer, making up about 85% of diagnoses. And yet it is rarely talked about.  Kidney Cancer is also an area which has seen significant progress in treatment options. Key takeaways from the webinar are given below. 

Key takeaways from the session: 

What is the incidence of Kidney Cancer in India?

Approx. 17,000 new cases are detected every year. The prevalence is 39,000 cases. It is ranked 21st among the cancers detected in India. Number of deaths are 9897, this indicates that patients come in late and if they came early, they would have a better chance of survival.

What is kidney cancer?

These are tumours that arise from the kidney parts: the upper, middle and lower pole. The renal pelvis is mostly seen in urinary bladder cancer, whereas kidney cancers are seen in the upper and lower poles.

Causes & Risk Factors of Kidney Cancer

• Exposure to petroleum and cadmium
• Obesity
• Family history due to inherited syndromes (about 4%)
• 85% of cases are due to solitary tumours
• Tobacco

In majority of patients, the cancer was an incidental finding. If patient is symptomatic or has Polycystic kidney disease which require routine check-ups, then the cancer is detected early.

Are people with CKD at a greater risk?

No, there is no direct link between CKD and renal cancer.

Symptoms/signs of Kidney Cancer

• Most common one is hematuria, which is presence of blood in the urine. It can be microscopic meaning blood cells are detected in a urine sample or it can be gross where visible blood is seen in the urine.
• Swelling in the flank area
• Pain in the flank area
• Fatigue
• Weight loss
• Many patients come in the metastatic phase presenting with pain or cough.

Stages of Kidney Cancer

Stage 1: Localised, small and confined to the kidney.

Stage 2: Slightly bigger, may be present in the fascia and perinephric tissues. Cure is possible with good quality surgery.

Stage 3: Locally advanced tumour with local hilar node involvement and affecting surrounding tissues.

Stage 4/ Metastatic: Tumour can be of any size with positive nodes. Cancer cells have broken out into the blood vessels and can reach any part of the body and start growing there. In such cases, cure is relatively rare. Treatment is palliation and life prolongation.

How is staging done?

Besides a local scan with a CT or MRI, PET Scan is also done to check if the tumour has spread.

Types of Kidney Cancers

Most common is Clear cell adenocarcinoma. Other types are rare, these include papillary, Mercel cell, Sarcoma, Lymphoma etc.

Can Kidney cancer be a secondary cancer?

Kidney cancer rarely present as a secondary cancer. Patients with syndromes like Von-Hippel or Renal TB can be at a higher risk but it is rarely seen as a metastatic site for other cancers.

Treatment Options for Kidney Cancer

In the last 3 decades, there has been a lost of changes in kidney tumour treatment. In the olden days, kidney cancer treatment was restricted to Chemo and Radiotherapy which were widely ineffective. But now, new therapies are available. We have anti-VEGFR, TKIs, M-Tor inhibitors, HIF2a inhibitors, Check point inhibitors/Biological agents used in immunotherapy etc.. 

Broadly we have:

Targeted therapy: Most cancer produce a protein called VEGF ( vascular endothelial growth factor) which is responsible for forming new blood vessels for the tumour. Targeted drugs (inhibitors or antibodies) focus on blocking the VEGF receptors. One such antibody is the bevacizumab and similar agents (biosimilars) are very effective against kidney cancers. In 2005, Tyrosine kinase inhibitors (TKIs) were discovered, which changes the direction of treatment for Clear cell tumours. Axinitib, sorafini, sunitinib, tivozanib, cabozanitib, pazopnib and lenavtinib are all TKIs.

Immunotherapy or Biologic therapy works with the aim to strengthen the body’s own immune system to better fight the cancer. Interleukin-2, alpha-interferons and check-point inhibitors are some of the drug categories used in Immunotherapy. The side-effects are milder compared to other therapy areas. Treatment is tailored and depends on the patient’s cancer, stage/grade of tumour, general health, co-morbidities, and other precipitating factors. 

Combination therapy: Increasingly utilised in advanced disease, 2 form of therapy drugs are used together for a double attack on the tumour. For example, check point inhibitors may be paired with VEGF inhibitors.

Today, medical oncologist are able to provide various options in advanced stage disease thanks to these new therapy areas.

What is the primary mode of treatment for early stage?

The main treatment option is surgery. Timely, adequate surgery is the only option for cure. Surgery can be open, laparoscopic or robotic. In Metastatic stage, palliative surgery is considered if there is severe hematuria or pain but there is no survival benefit.

Potential complications of Treatment

Disease-induced complications include fatigue, anemia, hematuria, edema, low hemoglobin, protein loss, flank pain & swelling, weight loss and cachexia, loss of appetite, hypoalbuminemia and depression.

Treatment-induced complications are cachexia due to side-effects, depression, mucositis, ulceration, low platelets and hemoglobin, fatigue, weakness, loss of appetite etc.

How can patients manage the following complications?

Rash: Mild rash which is tolerable and does not affect day-to-day life of the patient can be ignored to heal on its own. However, if there is blister formation, hindrance to daily activities, or ulceration, then medication needs to be discontinued with the consult of the Oncologist. Urea creams, emollients, moisturizers and antibiotics are started. If the rash severity continues to increase, the dosage of the medications may be reduced.

Diarrhea: Renal cancer-induced diarrhea is non-infective, which is less harmful than gastroenteritis diarrhea. Treatment includes stopping medications, lots of water and ORS intake and anti-secretory agents like loperamide that will decrease the secretion.

Anemia: Anemia can be related to the disease or the treatment. When present as a symptom, it can advance as the cancer progresses but once the treatment starts, it should improve. In treatment-related anemia, it is often seen as a side-effect of TKIs. It has to be handled in different ways. If Hb drops below 7, then transfusion may be required with the aim to bring it up to above 9. If patient Hb is between 9 and 11, and there is fatigue, drugs like erythropoietin can be employed to bring it up to 13. It is also important to investigate and find the exact type of anemia, and then treat it accordingly. Supplements like folic acid, iron, B12 can be given once type of anemia is known. For patients in the 8-10 Hb category, iron injections can be given. Treatment has to be individualised and patients must be counselled on expected side-effects, treatment options and to understand that not all anemia can be corrected.

Hematuria: Gross hematuria does cause a lot of panic in patients. One needs to find if the cause is disease or blood related. If patient is on ani-coagulant drugs, they must be stopped temporarily, If there is any bleeding-disorder, then it must be corrected. If it is disease-related, then the option of surgery can be explored. If patient is unfit for surgery, then interventional radiological embolization or deliver of Hemostatic radiotherapy can be tried.

Swelling: Swelling can be of different causes. First of all, renal cancer has a high risk of causing deep venous thrombosis. This can lead to unilateral (one-sided) lower limb pain and swelling. The patient is sent for Doppler study to find if there is any clot in the veins. Anti-clotting drugs are then used to break/lyse the thrombus. Another cause of swelling can be generalised swelling due to renal failure. Many patients are living with a single kidney post-cancer surgery. If this single kidney also get affected by diseases like diabetes or hypertension, then the body will show signs of renal disease by swelling up. Yet, another cause can be a side-effect of treatment with immunotherapy drugs. Such swelling can be very dangerous and should be dealt with immediately.

Is Cachexia, weight loss and loss of appetite only seen in Stage 4 patients?

These 3 complications can be due to the cancer itself or a side-effect of the treatment. It is important to identify the underlying reason because often multiple issues occur simultaneously such as anemia, mucositis, depression, fatigue etc. For instance if the cause is depression, try to motivate the patient. Suggest yoga, meditation and medications to help the mental health. Most patients go through depression during some stage of their disease, whether they tell you or not. Financial burden is a common cause for depression. Treatment also leads to muscle wasting and weight loss because there is imbalance of proteins and vitamins. There can be hypoalbuminemia, low iron, ulcers in the mouth which can all come together.

Lifestyle changes that patients should follow post diagnosis:

These changes are recommendations for patients with any type of cancer.

• If you have a co-morbidity, follow them closely with your doctor. Make sure your diabetes, blood pressure, thyroid or neurological condition is under control.
• Make sure you drink adequate water as advised by your Nephrologist.
• Eat more vegetables and fruits
• Avoid foods high in potassium like coconut water.
• Decrease quantity of carbohydrates, sugar, salt and spices in your diet.
• Eat freshly cooked meals.
• You may not be able to eat a full meal in one go. Have 6 small meals in a day instead.
• Avoid smoking, alcohol and red meat intake.

Patients are referred to a dietician who can explain all of these things and how to prepare nutritious meals. Written guidelines are often shared with patients too. Dieticians may also provide recipes on how to make the food more palatable for the patient.

Yoga and meditation are also recommended to increase blood circulation, build on immunity and improve mental health. Don’t go for vigorous yoga but simple yoga that suits your body.

Certain immunity boosting foods include lemon, green tea, ginger, cinnamon, cardamom, turmeric and clove. These can alleviate side-effects and prevent infections like Covid.

Providing a more holistic approach to management and lifestyle has been found to be most helpful.

For people with a family history, what options are available to manage their concerns?

There are 6 to 7 inherited syndromes that are associates with kidney cancer. My advice to people who have a 1st or 2nd degree relative with kidney cancer is to always check the age at which the relative got the disease. Ten years prior to that, start going for screening methods. Every syndrome has a specific age and period for screening. Only 3-4% of patients with a familial inherited syndrome will go on to get kidney cancer. In India, incidence of kidney cancers in such patients is only 3.9%.

90% of cases are sporadic due to prolonged alcohol, tobacco, drug usage or with polycystic kidney diseases.

Survivors often struggle with lower back pain, how should they manage it?

If there is severe back pain, patient should immediately see their Oncologist because there is a chance of it being metastatic. Bone in the pelvic, lumbar and thoracic area is the most common site of metastasis. Hence, back pain should not be ignored by a survivor. Once the cause has been ruled out, then doctor can prescribe physiotherapy, medication, supplement etc for relief. Osteoporosis is not associated with kidney cancer!

Warning signs survivors should look out for?

• Bone pain not relieved by normal pain relief meds and increasing in intensity and causing movement restriction. Can be a sign of bone metastasis.
• Chronic cough persisting for more than a month with no relief. Can be a sign of lung metastasis.
• Early morning or throbbing headaches, nausea, vomiting can all be signs of brain metastasis.

Routine Follow-Up

Post surgery, patients are called every 3 months for a check-up. This includes a blood test with CBC, renal and liver function test, lactase dehydrogenase to check for any indication of metastasis. For example, sudden fall in hemoglobin, increase in alkaline phosphatase or lactase dehydrogenase can be a warning sign.

Ultrasound of thorax and abdomen is done every 6 months.

CT scan of thorax and abdomen is done annually.

If you have any warning signs, you must not wait for your next follow-up, but bring it to the attention of your Oncologist right away.

Once a patient is diagnosed and enters Cancerland, what questions can they ask their doctor to alleviate their anxieties?

We should tell patients that cancer is a treatable disease, so patients should not panic. Since survivors are left with one functioning kidney, they should now focus on taking good care of that kidney. This includes avoiding drugs that are toxic to the kidney. Whenever they consult a doctor, they must inform them about their kidney history, so they are not prescribed renal toxic drugs. Patients must be educated about possible sites of metastasis and their warning signs. Reassurance is very important. Their family physician should also be kept in the loop about their cancer.

Financial assistance

From a government perspective, the Ayushman Bharat yojana (PMJAY) provides roughly a 5 lakh package which covers chemotherapy and surgery. States like Himachal Pradesh, Gujarat, Orissa etc have their own schemes as well. Pharma industries have launched various assistance programs to provide pricey innovative drugs for free to patients below the poverty line. For instance, BioCon has a patient assistance program called ACE (Assist, care and educate). There are ongoing clinical trials where there is an open-label extension phase where patients continue to receive medications for life. If you need financial aid for cancer treatment, feel free to ask your doctor and social worker about available options.