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An expert explained the advantages and disadvantages of radiation as a treatment for patients with renal cell carcinoma, a type of kidney cancer.

Discussing Radiation as a Treatment Option for Kidney Cancer

Discussions with the care team around radiation as a treatment option for patients with renal cell carcinoma, a type of kidney cancer, should focus on its advantages and disadvantages, in addition to how these can best meet patient needs, an expert said.

Renal cell carcinoma, according to the National Cancer Institute, is the most common type of kidney cancer in adults. The disease starts in the lining of the small tubes in the kidney that return filtered substances back to the blood that the body needs.

Radiation for renal cell carcinoma can be used to 

 and control disease in a minimally invasive manner.

CURE ®spoke with Dr. Chad Tang, associate professor in the Department of Radiation Oncology at The University of Texas MD Anderson Cancer Center in Houston, to learn more about radiation therapy as a treatment option for patients with renal cell carcinoma.

So I think — radiation is a local therapy. It takes care of an anatomical site in terms of controlling it or removing the disease. I think the other local therapy options out there are surgery and IR-based interventions, interventional radiology-based interventions, such as ablation through heat or through cold.

The advantage of radiation is that it's non-invasive. It requires no anesthesia or even sedation for most patients to treat. And it can be relatively quick, although it might take a week or two for the radiation to be completed.

One disadvantage is that you're not going to give tissue-like surgery, and maybe the effects of radiation may not be as immediate in terms of relieving symptoms as physically removing the tumor.

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Radiation therapy for renal cell carcinoma offers a non-invasive treatment option, focusing on symptom management and disease control. It is advantageous due to its minimal invasiveness, requiring no anesthesia or sedation, and can be completed relatively quickly. However, it does not provide tissue samples like surgery, and its effects may not be as immediate in symptom relief. Discussions with the care team should weigh these pros and cons to align with patient needs, considering other local therapies like surgery and interventional radiology-based interventions.

An expert explained how radiation may be a treatment option for patients with renal cell carcinoma to manage symptoms and control disease. 

Managing Symptoms, Controlling Disease With Radiation in Kidney Cancer

Radiation may be an effective treatment option to manage symptoms and control disease in patients with renal cell carcinoma, a type of kidney cancer, an expert said.

 to learn more about the indications for which radiation may be considered in patients with renal cell carcinoma. Tang is an associate professor in the Department of Radiation Oncology at The University of Texas MD Anderson Cancer Center in Houston.

I think there are two big categories for patients where radiation could be helpful. No. 1 is when a spot of cancer, such as in the bone or in the brain, is causing symptoms or threatening to cause symptoms such as close to the nerve routes in the spine. Radiation is minimally invasive. There won’t be any cutting or poking or prodding of the patient, so you can easily and effectively apply their radiation therapy sequenced with whatever drug therapy your medical oncologist has you on to alleviate or prevent the symptoms from recurring. That’s one category.

The second category is controlling the disease. Renal cell carcinoma is a disease that is known to evolve a lot. So different sites to the body can be very different genetically than other sites. And sometimes they evolve in a way that makes them resistant to the drug therapy or they’re so slow in their growth. In those instances, when it’s just a local site that’s causing problems because it’s resistant or only the site growing, we can take care of that site with radiation therapy, often with a very short course, and give you more time on the current drug that your medical oncologist has you on or buy you time off the drug.

Radiation therapy can be a valuable treatment for renal cell carcinoma, particularly in two scenarios. First, it can alleviate symptoms or prevent complications when cancer affects areas like the bone or brain, offering a minimally invasive option that complements ongoing drug therapies. Second, radiation can control disease progression in cases where cancer sites become resistant to drug treatments or exhibit slow growth. By targeting specific problematic sites, radiation can extend the effectiveness of current drug regimens or provide a break from them, enhancing overall patient management.

An expert explained how radiation may be a treatment option for patients with renal cell carcinoma to manage symptoms and control the disease. 

For patients with kidney cancer, understanding how palliative care can help is essential throughout the treatment process.

Palliative care, according to the Mayo Clinic, is medical care that specializes in relieving pain and symptoms associated with an illness. This type of care can also help patients cope with treatment-related side effects.

However, there’s more to palliative care than just relieving symptoms. It also “aims to help patients and families in one of three major categories,” Dr. Pallavi Kumar explained during an interview with CURE®.

Kumar is the director of Oncology Palliative Care and assistant professor of Clinical Medicine in the hematology-oncology division at the University of Pennsylvania.

She noted that the three categories of palliative care include:

Complex symptom management, such as pain, nausea or fatigue

Palliative care support via counseling or coping support from social workers

Planning for the future to best provide for patients’ goals and values

Knowing When Palliative Care Is Appropriate During Kidney Cancer

Previously, palliative care was not given until treatment options ran low, which was often towards the end of patients’ lives, Kumar said. Now palliative care may be appropriate during any point of patients’ experiences with kidney cancer, but particularly when they experience uncontrolled symptoms, ask for more support or need to refocus their goals and values.

“Palliative care can often help just bring everybody together for the sake of the patient and talk about what the goals are, what the medical realities are and how we [can] align the care with the patient’s goals,” Kumar explained. “There are many opportunities to involve palliative care, but usually I'd say if things are changing and we're worried that the patient's not going to necessarily recover back to where they were, that's probably a time to refer to palliative care.”

If patients’ quality of life is affected by either their treatment or cancer, it’s also a good time to consider starting palliative care, she said.

Why Palliative Care Is Important to Consider

Visits with an oncologist may be “jam-packed” with physical exams, toxicity reviews or symptom reviews and discussions about lab results and scans, Kumar noted.

“The visit is very packed, so sometimes there isn’t time or the space in a routine visit to talk about what happens if plan A doesn't work, what plan B looks like and [whether] plan B aligns with [patients’] goals and values,” she added. “There's not often a lot of time to unpack some of those things before a crisis happens, so having access to palliative care offers another space for you to talk through what might be your goals and values.”

She emphasized that although oncologists “do a fantastic job” at explaining these goals, values and plans, sometimes going beyond their care is necessary. For example, this may include working with palliative care teams who specialize in pain or symptom management, she explained, which will help with quality of life.

Advice for Patients With Kidney Cancer Considering Palliative Care

For patients with kidney cancer who are looking to utilize palliative care, Kumar recommended asking their oncology team about it and the best time it may be useful to them. Once patients start receiving palliative care, she also suggested that patients write down questions regarding quality of life before their visit.

“Think about this well before you ever need it. Please think about the one or two people in your life who you would trust to make medical decisions on your behalf,” Kumar said. “I have a lot of patients with adult children, but no one really knows who the medical person is [or] who the financial, legal person is.

“I’d say, just designate these things very clearly and have these conversations with your loved ones, so that if anyone's ever called on to make medical decisions on your behalf, they know who they are. Please try to talk with your family about what your wishes for future care might be. Advanced care planning is the best gift you can give to a loved one, so that they're not ever put in a position where they're guessing what you might want, fearing that they chose the wrong decision for you, or making a decision you wouldn't have made for yourself.”

Patients with kidney cancer who want more support during treatment can consider palliative care, whether it’s for symptoms or discussing goals and values.

Palliative Care in Kidney Cancer More Than Just Relieving Symptoms

For patients with kidney cancer who require postsurgical treatments, it’s important for them to know what to expect regarding treatment type, side effects and the healing process, an expert told CURE®.

However, not every patient with kidney cancer will undergo postsurgical treatments, Dr. Randall Lee, an assistant professor in the Department of Urology at Fox Chase Cancer Center in Philadelphia, said during an interview with CURE®. He noted that this decision is made based on pathologic features of the kidney tumor, which are abnormal characteristics seen in cells or tissue.

“[Doctors] basically take the patients to surgery if we think that this is a localized kidney tumor — localized, meaning that we don't see anything else on the scans of metastatic disease,” Lee said during the interview. “We want to make sure that we're giving the patients the opportunity for surgical cure in these situations. So, if we think that the tumor and the malignancy are confined to the kidney, we will offer them surgical therapy.”

Postsurgical Immunotherapy for Kidney Cancer

Systemic treatments, Lee said, are the types of postsurgical treatments patients may receive if it’s necessary.

“For patients who have high-risk or aggressive features of their kidney tumor, that is when we would start to recommend treatment for the entire body — systemic treatment options,” Lee explained. “[Although,] it’s not in the form of chemotherapy. It’s actually in the form of immunotherapy.”

Immunotherapy is a type of therapy that stimulates the immune system, which may help the body destroy cancer cells, according to the National Cancer Institute.

Specifically, Keytruda (pembrolizumab), a type of immunotherapy, is the postsurgical treatment patients would receive, according to Lee. Lee noted that previous clinical trials determined that 

 improved disease-free survival (time living without signs or symptoms of cancer).

When patients receive their postsurgical treatment plans, they should expect to receive an infusion of Keytruda approximately every three weeks for up to one year.

“During that treatment time, [patients will undergo] surveillance, imaging and scanning,” Lee said.

What Patients Can Expect Before and After Postsurgical Treatment

Before undergoing postsurgical treatment, Lee said there isn’t necessarily anything patients must do. Instead, he explained what patients can do to heal once they’re about to undergo surgery and then after postsurgical treatment.

“Anytime I take a patient to the operating room [for] surgery, I think the healing process after it is the most important to make sure that patients are up and moving around [and] that they’ve recovered,” Lee said. “Basically [making sure] their functional status is as close to baseline … and [that] everything is healed up in preparation [for them] to receive their infusions and their treatments.”

After receiving postsurgical treatment, Lee advised that patients to “keep close contact” with their medical oncologists and urologists, especially regarding side effects. Common side effects patients may experience include fatigue, diarrhea, itchy skin and some joint pain, Lee said.

“The urologist and medical oncologists are helping steer the management of all of this,” Lee emphasized. “It’s really important that if [patients] are having side effects to [postsurgical] treatment that we really want to know. This way, we can get ahead of it, maybe we must talk about changing our game plan as far as which treatment strategy to give [patients].

“If [patients] are having a lot of side effects, we may need to rethink that treatment pathway.”

For patients with kidney cancer undergoing postsurgical treatments, it’s key to understand how immunotherapy works and what side effects to look for. 

Expectations for Postsurgical Treatments in Kidney Cancer

When it comes to radiation therapy, there is plenty for patients with kidney cancer to discuss with their care teams, as Susan Poteat, 

Poteat is a medical physicist specializing in radiation therapy, as was her husband, who died approximately 15 months ago after living with metastatic kidney cancer for 15 years. She spoke with CURE® about some of the things that patients need to keep in mind and conversations they should have with their care teams about radiation therapy.

When discussing a study on stereotactic ablative body radiotherapy (SABR), Poteat noted that “there are multiple terms that get used to describe [the act of] using many, many beams of radiation to tightly focus on a small target and be able to give a large dose there,” stating that some may be more familiar, for example, with SBRT, or stereotactic body radiotherapy.

“I do encourage patients to remember that it is skill-dependent — just like you wouldn't have a difficult surgery done at a community hospital, you shouldn't have SABR done at a community hospital in general,” she said. “... A lot of community hospitals have experience using SABR in lung [cancer] and there's usually nothing too delicate nearby, but when we start talking about in the abdomen, there are a lot of radiosensitive tissues there and a lot of special considerations. So, I think [patients] should talk to their oncologist in some cases about using SABR in their course of treatment, but they also should talk to their oncologist about where's the nearest academic center with an outstanding radiotherapy program.”

The use of SABR, Poteat said, has “a very, very clear space for patients who get just a few brain [metastases],” stating kidney cancer metastasizes to the brain for approximately 30% of patients.

Additionally, Poteat said, “we have a lot of patients who are doing very, very well on their drug treatment, and then there's this one spot that pops up, it's developed some sort of resistance, it's growing on multiple scans. If everything else is going well, the patient can very likely extend their time on that particular drug by ablating that single place that's the bad actor and is growing.”

“Community physicians may not bring that [strategy] up,” she said. “So, it's appropriate for patients to ask about that. And ask who they could ask for a referral to radiation therapy and go talk to someone who's knowledgeable about that.”

“I do think, more than anything else, knowing that your medical oncologist may not think about whether radiation would help the current thing that just popped up for you [is important],” Poteat said. “And it's OK to ask, ‘Is there any point in me talking to a radiation oncologist about this?’ He's very likely going to refer you for a bone [metastasis] or brain [metastasis]. But there are other times in your care path [when] you might wonder [about radiation], and it's fine to ask.”

An expert explains what patients need to keep in mind and what conversations they should be having with their care teams.

What Patients With Kidney Cancer Need to Know About Radiation Therapy

An expert said that he is optimistic about the future use of biomarkers in the kidney cancer space. 

What Are Biomarkers and How Are They Used in Kidney Cancer? 

Not all patients with kidney cancer need to undergo extensive biomarker testing with the current treatments available, but Dr. David A Braun said that he is optimistic about the future of biomarker testing for this patient population.

According to the American Cancer Society, “biomarkers are genes, proteins or other substances that can be tested for to reveal important details about a person's cancer.” Oftentimes, biomarkers can be used to determine more personalized treatments for patients or lend insight into their prognosis.

The most common biomarker used in the kidney cancer space is determining whether patients’ disease have sarcomatoid or rhabdoid histology, which could indicate that patients are more likely to respond to immunotherapy or other targeted therapies, explained Braun, who is an assistant professor of Medicine at Yale Cancer Center.

 to discuss the current and future use of biomarkers in patients with kidney cancer.

Not all kidney cancer patients undergo extensive biomarker testing, meaning genomics and transcriptomics. And these sorts of things. But I think the real answer is they shouldn't at this stage.

I'm really optimistic about biomarkers. I think they play an important role, and I think we'll see lots of developments in the years to come. But if we were to sit here and say, ‘Today, how does this affect my practice? Monday morning in the clinic, how's this going to affect that kidney cancer patient in front of me?’

Really, the only biomarker at this point that's actionable is not something new, it's not advanced. It doesn't catch headlines, but it's looking under the microscope and understanding the histology. And particularly for kidney cancer, it's having sarcomatoid or rhabdoid histology. Those features are really suggestive of something that's much more likely to respond to immunotherapy and much less likely to respond to other targeted therapies. And so again, where my hope is, [that] we'll eventually enter an era where sequencing and single-cell approaches will have really utility and I think we will get there. But where we are right now, it's really the histology that looking at a microscope that plays the biggest role in terms of biomarkers.

Transcript was edited for clarity and conciseness.

'No Stupid Questions' for Newly Diagnosed Patients With Cancer

Finding a patient support group could be essential after being diagnosed with kidney cancer, explained Dr. Rachel Giles, chief executive officer of the International Kidney Cancer Coalition.

In a recent interview, Giles explained that the time after diagnosis can be extremely overwhelming for patients, as they navigate treatment options and side effects. By becoming educated about their disease and joining a group of individuals who have gone through something similar, this burden can be a bit easier to bear, Giles said.

It's all about getting the right information. And like I said, the most vulnerable time for a patient is after diagnosis when they have been told that they have cancer, in this case. And (regarding) the choice that they make the treatment that they start, there is a huge amount (of decisions) … often just a few short weeks. And in those that period of time, the patient has to become essentially an expert in their disease condition and figure out all the options plus perhaps what their doctors may not be telling them. So sometimes you have the guidelines that are approved in whatever country you are, and you need to compare that with what the options are, that are being provided, because some hospitals may leave out options. So we try and help that.

But typically, I tell patients to go find a patient organization; this will support you tremendously at all levels. They'll give you information, you'll find a peer-to-peer support system where you'll learn about your condition, and perhaps people can turn you on to ideas you've never even thought about. And also during treatment, of course, this is a very helpful resource because you actually have someone to turn to and say, “I am having a lot of diarrhea,” for example. “What products and what stores do you buy (medications to help) at?” It can be very specific and that's, that's tremendously useful information.

So I would tell patients to take the time to breathe in, breathe out. There's a lot of information out there, it's not impossible, but it is a lot of work, and it's hard to do when you're dealing with the impact of a problem, possibly an out-of-the-blue of a diagnosis.

In the situation of kidney cancer there, it's typically asymptomatic — you have no symptoms whatsoever. And you we found a lot of people, for example, were being diagnosed with the renal masses, as they call them during COVID, because they were going to get their lung CT. And the kidneys are behind the lungs. So that would come up in the imaging. And we had, I think, all the patient organizations in kidney cancer (space) got that huge uptake in phone calls, and requests for support because they didn't know what to do with these small renal masses. You know, we don't know if they're really going to be cancer or not what they are, it could take years before they become anything scary. But no one really knows and there's no guidelines for that.

So the idea is to just find your patient organization, try and find a partner. You know, some people get binders and actually put all the information into one place. Whatever works for you, is convenient, but do take the time to understand the information and ask questions. Don't be scared. There are no wrong answers, no stupid questions. And it's important to be aware that your options are what they are and that they're the right options, that they're guidelines that they're compliant to the guidelines, make sure that you're getting what you should be getting. And but typically, that's not a problem. It's just occasionally and just ask questions.

An expert stressed the importance of finding a patient support group and asking questions after being diagnosed with kidney — or any other form — of cancer. 

Kidney Cancer

LIVING WITH CANCER

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