Metastatic and Recurrent Kidney Cancer
Metastatic Disease: The Landscape
- When the cancer has recurred or spread to distant organs, there is a real
chance for long term survival or even cure with the best treatment and
this is true even though the prognosis and the odds are poor, as is median
survival. (I highly recommend reading The
Median Isn't the Message here on
CancerGuide to better understand why poor median survival does not preclude
the possibility of long term survival or even cure).
- Renal cell carcinoma, while not truly rare, is also not common and the
treatment differs from that of most cancers. Therefore the average oncologist
may not have much experience with the disease and its treatment. In my opinion
many patients are not offered the best treatment. This means it's important to
find experts in the disease and also to do your own research.
- Many patients are told that renal cell cancer is a slow growing disease,
but in truth the word which best characterizes its rate of growth is
"variable". While, without effective treatment, the disease usually
progresses rapidly, patients occasionally enjoy long periods of stability, even
several years, without any treatment at all. Some patients even have their tumors
shrink or disappear entirely without treatment.
- While much is made of so-called "spontaneous remission" in the
popular literature on exceptional recoveries from cancer, the truth is that
spontaneous remission is exceedingly rare in most types of cancer. Renal cell
cancer is one of the few exceptions, and here spontaneous remissions are well
documented and are always a reason for hope. These remissions can be complete
and long lasting, but are often partial and temporary. Estimates of how often
spontaneous remissions occur vary and range from the order of a few percent of
cases to a few tenths of a percent of cases. This relatively high rate of
spontaneous remission was one early clue that RCC might be one of the cancers
most susceptible to immunotherapy.
- Clinical trials are an important part of this landscape. Because the best
treatments are so very far from ideal, many patients who go to major medical
centers or recognized experts will be offered clinical trials, and anyone who
investigates options on their own will soon be looking at clinical trials.
Clinical trials can be a great way to get cutting edge new treatment but they
also very greatly in their promise, and are not automatically better than the
best standard treatments, especially for first line treatment. For more on how
and where to approach investigating clinical trials for advanced RCC, see Clinical Trials for Advanced Kidney Cancer, Promise and
- It has long been recognized that surgery for a solitary metastasis can lead
to many years of remission and even an occasional cure. In fact, data has
gradually accumulated over many years that extends these findings to cases
where there is more than just a single metastasis, if all of the tumors can be
completely removed. If such surgery would be reasonable for you, this could
well be your most likely route to a remission. For two detailed reviews of the
emerging data, see Surgery for Metastatic RCC.
- RCC is one of the few cancers which has been found to be susceptible to
immunotherapy. Immunotherapy is therapy which manipulates your natural immune
system so it recognizes and destroys cancer cells. Immune stimulating drugs
such as Interleukin-2 and
Alpha Interferon are the mainstay of current pharmaceutical treatment and
immunotherapy. In particular, Interleukin-2 based therapy sometimes yields very
long term remissions and apparent cures.
- Clear cell kidney cancers typically contain a very dense network of new
blood vessels that feed the tumor, and furthermore clear cell RCC cells have
known genetic defect (non-functioning VHL gene) which specifically drives blood
vessel growth. A new approach in cancer therapy called "antiangiogenic therapy"
targets tumor blood vessels. While no antiangiogenic therapy for RCC is yet
standard this approach is being intensively explored and there are many
clinical trials testing antiangiogenic drugs. One antiangiogenic drug, Thalidomide, is in common use as a second line
therapy as well as in some more exciting combination trials. A new
antiangiogenic drug, Avastin, is about to be approved for colon cancer, and
has shown some promise in RCC, where it is being tested further. Other
antiangiogenic drugs are in clinical trials.
- Renal cell cancer is notoriously resistant to cytotoxic chemotherapy drugs.
These classic "chemo" drugs interfere with dividing cells in a relatively
non-specific way. Given the extensive and very poor record of these drugs, I
believe most RCC patients should avoid cytotoxic chemotherapy as sole therapy.
- Things are different for some of the rarer
subtypes of RCC so it's important to know what kind of RCC you have. In
particular, long lasting responses to cytotoxic chemotherapy are sometimes
possible in sarcomatoid RCC (unlike most types of RCC). Papillary RCC appears
to be relatively unresponsive to immunotherapy, again unlike the common clear
cell variety. For details, see my article on
subtypes of RCC.
Finally, some thoughts on maximizing your chances in the strange and austere
landscape that is metastatic kidney cancer... what follows will help you
understand how I've evaluated treatment options, and may clarify your thinking
or inspire to your own path.
- I think the best strategy is to use the treatment at each point which
offers the best current odds given your situation. There are some possible
- When choosing treatments, I prefer to rely on evidence that it helps actual
people with RCC rather than results from animal or test tube experiments or
results in other cancers. Certainly actual evidence is much better than mere
- I believe the best proven treatments at this time are Interleukin-2, preferably at high dose, and Surgery. These treatments offer a small but real
chance of a long term remission or even cure.
- It takes years to show the kind of long-term durability these treatments
can produce. The odds with these treatments are not satisfactory, but the long
term survivals are a precious gem not to be thrown away lightly. The length of
time required to get long term results makes it hard to know when a new and
promising treatment might actually improve the long-term odds. Unfortunately,
very few novel treatments turn out to actually be an advance. Therefore, you
should consider novel treatments for first line therapy only if there is strong
early evidence to suggest that the new treatment will turn out to be better
than the standard first line therapies. This would include a substantially
better response percentage in prior studies with those responses holding so far
(the longer the follow-up the better).
- If surgery or IL-2 have been tried without success, then one should be much
more open to treatments with only early and uncertain signs of success. Early
and uncertain signs of efficacy are much better than no evidence of efficacy.
- Because this disease itself is such risky business, the risks of the
disease virtually always exceed the risk of treatment regardless of what the
risks of treatment actually are. Clinical trial consent forms, some doctors,
and for those here in the states, perhaps even American culture itself, all
tend to focus on the risks. If you want to live, you had better focus on the
potential benefits. Keep your eyes on the prize.
This CancerGuide Page By
Steve Dunn. © Steve Dunn
Page Created: January 18, 2004,
Last Updated: January 21, 2004