Cancer Association of South Africa (CANSA) Fact Sheet on Kidney Cancer

Transcription

1 Cancer Assciatin f Suth Africa (CANSA) Fact Sheet n Kidney Cancer Intrductin The kidneys are tw rgans that serve several essential regulatry rles in man. They frm an essential part f the urinary system and als serve hmestatic functins such as the regulatin f electrlytes, maintenance f acid base balance and regulatin f bld pressure (by maintaining salt and water balance). They serve the bdy as a natural filter f the bld and remve wastes which are diverted t the urinary bladder. In the prcess f prducing urine, the kidneys excrete wastes such as urea and ammnia. They are als respnsible fr the reabsrptin f water, glucse, and amin acids. The kidneys als prduce hrmnes including calcitril, erythrpietin, and the enzyme renin. Many f the kidney's functins are accmplished by relatively simple mechanisms f filtratin, reabsrptin, and secretin, which take place in the nephrn. Filtratin, which takes place at the renal crpuscle, is the prcess by which cells and large prteins are filtered frm the bld t make an ultrafiltrate that eventually becmes urine (WebMD). [Picture Credit: Urinary Tract Anatmy]. Lcated at the back f the abdminal cavity in the retrperitneum, the kidneys receive bld frm the paired renal arteries, and drain int the paired renal veins. Each kidney excretes urine int a ureter, itself a paired structure that empties int the urinary bladder. [Picture credit:: Urinary Tract Anatmy]. Cancer f the Kidneys Kidney cancer is the uncntrlled grwth f abnrmal cells in the kidneys. Cancerus cells are als called malignant cells. Each persn diagnsed with kidney cancer ges thrugh the shck f being tld they have the disease. It is a difficult experience. January 2016 Page 1

2 Feelings f shck, lneliness, alienatin, fear, frustratin, anger, and hurt are natural parts f any life-threatening illness. It is kay t have these feelings, t cry, and t be upset. After the shck f diagnsis, it's time t start healing. One shuld nt let ne s emtins and cancer diagnsis destry ne s hme life r relatins with the imprtant peple in ne s life. They may als be hurting inside, fearing fr their lved and as well as themselves. When cancer strikes, it hits the whle family (Kidney Cancer Assciatin). Sme patients are diagnsed befre the cancer has metastasised (spread) t ther parts f the bdy, while thers have metastatic disease when their cancer is initially diagnsed. Surgery may be the first curse f treatment. If surgery is dne first, additinal treatment may be recmmended t delay the cancer's return, r t treat metastatic disease. Incidence f Kidney Cancer in Suth Africa Accrding t the Natinal Cancer Registry (2010) the fllwing number f Kidney Cancer cases was histlgically diagnsed in Suth Africa during 2010: Grup - Males 2010 N f Cases Lifetime Risk Percentage f All Cancers All males 281 1:584 1,03% Asian males 17 1:422 2,27% Black males 109 1: ,03% Clured males 44 1:309 1,36% White males 111 1:236 0,88% Grup - Females 2010 N f Cases Lifetime Risk Percentage f All Cancers All females 197 1: ,66% Asian females 16 1:514 1,71% Black females 101 1: ,65% Clured females 10 1: ,33% White females 70 1:426 0,69% The frequency f histlgically diagnsed cases f Kidney Cancer in Suth Africa fr 2010 was as fllws (Natinal Cancer Registry, 2010): Grup - Males All males Asian males Black males Clured males White males Grup - Females All females Asian females Black females Clured females White females N.B. In the event that the ttals in any f the abve tables d nt tally, this may be the result f uncertainties as t the age, race r sex f the individual. The ttals fr all males and all females, hwever, always reflect the crrect ttals. January 2016 Page 2

3 Risk Factrs fr Kidney Cancer A risk factr is anything that affects ne s chance f getting a disease such as cancer. Different cancers have different risk factrs. Fr example, unprtected expsure t strng sunlight is a risk factr fr skin cancer. Having a risk factr, r even several risk factrs, des nt mean that yu will get the disease. Several risk factrs that may make ne mre likely t develp kidney cancer have been identified. Lifestyle- and Wrk-related Risk Factrs Smking Smking increases the risk f develping renal cell carcinma. Smking has been shwn t duble the risk f kidney cancer and cntributes t as many as ne-third f the cases. The increased risk seems t be related t hw much ne smkes. The risk increases the lnger ne smkes and decreases after ne quits, althugh it takes years t reach the same risk level as smene wh has never smked. Obesity Peple wh are very verweight have a higher risk f develping renal cell cancer. Sme dctrs think besity is a factr in abut 2 ut f 10 peple wh get this cancer. Obesity may cause changes in certain hrmnes that can lead t renal cell carcinma. Wrkplace expsures Many studies have suggested that wrkplace expsure t certain substances increases the risk fr renal cell carcinma. Sme f these are petrleum prducts, asbests, cadmium (a type f metal), sme herbicides, benzene, and rganic slvents, particularly trichlrethylene. (Natinal Institutes fr Health; May clinic; Clumbia University Medical Centre) Genetic and Hereditary Risk Factrs Genetic factrs have been linked t an increased risk f kidney cancer. Sme peple inherit a tendency t develp certain types f cancer. It is imprtant that peple wh have hereditary causes f renal cell cancer see their dctrs frequently, particularly if they have already had a renal cell cancer diagnsed. Sme dctrs recmmend regular imaging tests (such as CT scans) fr these peple. Peple wh have the cnditins listed here have a much higher risk fr getting kidney cancer, althugh they accunt fr nly a small prtin f cases verall: vn Hippel-Lindau (VHL) disease Peple with this hereditary disrder ften develp several kinds f tumurs and cysts (fluid-filled sacs) in different parts f the bdy. They have an increased risk fr develping clear cell renal cell carcinma, especially at a yunger age. They may als have benign tumurs in their eyes, brain, spinal crd, pancreas and ther rgans; and a type f adrenal gland tumur called phechrmcytma. This cnditin is caused by mutatins (changes) in the VHL gene. Hereditary papillary renal cell carcinma Peple with this cnditin have inherited a tendency t develp ne r mre papillary renal cell carcinmas, but they d nt have tumurs in ther parts f the bdy, as is January 2016 Page 3

4 the case with the ther inherited cnditins listed here. This disrder is linked t changes in many genes, mst ften the MET gene. Hereditary leimyma-renal cell carcinma Peple with this syndrme develp smth muscle tumurs called leimymas r fibrids f the skin and uterus (in wmen) and have a higher risk fr develping papillary renal cell cancers. It has been linked t changes in the fumarate hydratase (FH) gene. Birt-Hgg-Dube (BHD) syndrme Peple with this syndrme, which is characterised by the develpment f small benign skin tumurs, have an increased risk f develping different kinds f kidney tumurs, including renal cell cancers and nccytmas. They may als have benign r malignant tumurs f several ther tissues. The gene linked t BHD is fficially knwn as flliculin (FLCN). Hereditary renal nccytma Sme peple inherit the tendency t develp a kidney tumur called nccytma, which has a very lw ptential fr being malignant. (Natinal Institutes fr Health; May clinic; Clumbia University Medical Centre) Other risk factrs Other risk factrs include: Family histry f kidney cancer Peple with a strng family histry f renal cell cancer (withut ne f the knwn inherited cnditins listed previusly) als have a 2 t 4 times higher chance f develping this cancer. This risk is highest in brthers r sisters f thse with the cancer. It is nt clear whether this is due t shared genes r smething that bth peple were expsed t in the envirnment - r bth. High bld pressure The risk f kidney cancer is higher in peple with high bld pressure. Sme studies have suggested that certain medicines used t treat high bld pressure may raise the risk f kidney cancer, but it is hard t tell if it is the cnditin r the medicine (r bth) that may be the cause f the increased risk. Certain medicines Phenacetin, nce a ppular nn-prescriptin pain reliever, has been linked t renal cell cancer in the past. Because this medicine has nt been available fr ver 20 years, this n lnger appears t be a majr risk factr. Over-The-Cunter Pain Relievers: many ver the cunter pain relievers are smewhat txic t the kidney. These nn-steridal anti-inflammatry drugs include aspirin, ibuprfen, and naprxen. Trade names fr ibuprfen and naprxen include Mtrin, Advil, and Aleve. Lng term use f acetaminphen (Tylenl) has als been assciated with kidney failure. Diuretics Sme studies have suggested that diuretics (water pills) may be linked t a small increase in the risk f renal cell carcinma. It is nt clear whether the cause is the drugs r the high bld pressure it treats. January 2016 Page 4

5 Advanced kidney disease Peple with advanced kidney disease, especially thse needing dialysis, have a higher risk f renal cell carcinma. Dialysis is a treatment used t remve txins frm yur bdy if the kidneys d nt wrk prperly. Sex Renal cell carcinma is abut twice as cmmn in men as in wmen. Men are mre likely t be smkers and are mre likely t be expsed t cancer-causing chemicals at wrk, which may accunt fr sme f the difference. Physical activity An active lifestyle has many psitive healthy benefits including decreasing high bld pressure, strengthening bnes, helping t maintain a healthy weight, and reducing the risk f kidney cancer. It is imprtant t discuss an exercise r physical activity regimen with yur dctr - mst physicians suggest getting at least 30 minutes a day f exercise. Alchl cnsumptin Alchl use is a cause f cancer. Any level f alchl cnsumptin increases the risk f develping an alchl-related cancer; the level f risk increases in line with the level f cnsumptin. There is cnvincing evidence that alchl use increases the risk f cancers f the muth, pharynx, larynx, esphagus, kidney, bwel (in men) and breast (in wmen), and prbable evidence that it increases the risk f bwel cancer (in wmen) and liver cancer. Age Accrding t the internatinal literature, the risk f renal cell carcinma significantly increases with age, mst kidney cancers ccur in peple ver 45 years f age; with the highest incidences between the ages f 55 and 84. Kidney cancer is mstly a disease seen in adults aged ver 55, and is rare in children (Kidney Health Australia). In Suth Africa, accrding t the Natinal Cancer Registry f 2004, there is a high incidence f kidney cancer in the 0 t 9 year age grup with a peak in the 45 t 69 year age grup in bth males and females. Dialysis Peple wh receive lng-term dialysis fr treatment f chrnic renal failure are at greater risk f develping kidney cancer, pssibly because renal failure depresses the immune system. Peple wh have a kidney transplant and receive immunsuppressant drugs als are mre likely t develp kidney cancer. Radiatin In sme cases, expsure t radiatin may increase the risk f kidney cancer. (American Cancer Sciety; Kidney Cancer Assciatin; Natinal Institutes f Health; Clumbia University Medical Center; Kidney Cancer Institute; Cancer Cuncil, New Suth Wales; Natinal Institutes fr Health; May clinic; Clumbia University Medical Centre) Diagnsis f Kidney Cancer Early kidney cancer des nt usually cause any signs r symptms. Mst kidney tumurs are fund incidentally during an evaluatin with radilgic imaging studies fr ther nnspecific abdminal cmplaints (gallbladder pain, fr example), r during fllw-up fr ther previusly treated malignancies. These incidental cancers are ften fund early, befre any symptms have ccurred. Because such cancers are usually detected befre they have spread, patients with incidental kidney tumurs are ften cured f their disease, January 2016 Page 5

6 cmmnly by surgery alne. As many as 30 percent f kidney masses represent a benign cnditin (Memrial Slan-Kettering Cancer Centre). Sme f the earliest signs and symptms f kidney cancer include: Bld in the urine (haematuria) Lw back pain n ne side (nt caused by injury) A mass (lump) n the side r lwer back Fatigue (tiredness) Weight lss nt caused by dieting Fever that is nt caused by an infectin and that des nt g away after a few weeks Swelling f the ankles and legs (edema) Nne f these symptms are psitively indicative f kidney cancer. Fr example, bld in the urine may be a sign f kidney, bladder r prstate cancer, but can als be an indicatin f a bladder infectin r a kidney stne (American Cancer Sciety). The fllwing tests and prcedures are used t diagnse kidney cancer: Bld and urine tests - tests f bld and urine may give the dctr clues abut what is causing the signs and symptms (May Clinic). Urinary aquaprin-i (AQP-1) and adipse differentiatin-related prtein (ADFP) as bimarkers f kidney cancer. This is a new prcess fr: early and nn-invasive detectin f renal cancer ppulatin screening fr renal cancer pst-treatment surveillance fr recurrence f renal cancer prgressin, regressin r time-curse f disease in untreated, partially treated, and definitively treated patients with renal cancer The prcess is nn-invasive, using readily available bilgical fluids such as urine and pssibly bld (Kharasch). Imaging tests - imaging tests allw a dctr t visualise a kidney tumur r abnrmality. Imaging tests might include ultrasund, cmputerised tmgraphy (CT) r magnetic resnance imaging (MRI). Remving a sample f kidney tissue (bipsy) - in sme selected cases, the dctr may recmmend a prcedure t remve a small sample f cells (bipsy) frm a suspicius area f a kidney. Because surgery is usually the first line treatment fr kidney cancer and a kidney bipsy carries the risk f a "false-negative," dctrs usually frg kidney bipsy. Kidney bipsy is typically reserved fr cases that are mst likely t be nncancerus r fr peple wh can't underg an peratin (May Clinic). Fine needle aspiratin (FNA) - are smetimes used t btain a bipsy f the kidney. This invlves the insertin f a lng, thin needle int the kidney t take a tiny sample f tissue fr examinatin under a micrscpe. With mdern bipsy methds, there is virtually n risk f spreading cancer (MD Andersn Cancer Center). January 2016 Page 6

7 Cystscpy and retrgrade pyelgraphy - if a dctr suspects that a kidney tumur is arising frm the cllecting system in the kidney, he/she may examine the patient using cystscpy and retrgrade pyelgraphy. Using a cystscpe (an instrument cnsisting f a slender tube with a lens and light that is placed int the kidney thrugh the urethra), the dctr can pass a small catheter int the pening f the ureter (the tube that carries urine frm the kidney t the bladder), inject dye, and take X-ray pictures f the entire cllecting system f the affected kidney t check fr pssible cancers. Intravenus Pyelgram (IVP) the dctr perfrms this examinatin by injecting a dye int the bldstream, which travels t the kidneys, ureters, and bladder t mre clearly utline these rgans n x-ray. IVP has been largely replaced by CT scans because the CT scan creates a cmputer enhanced recnstructin f the entire urinary tract and mre accurately identifies small tumurs (Clumbia University Medical Centre). Types f Kidney Cancer Renal Cell Carcinma (RCC) - Renal Cell Carcinma (RCC) is the mst cmmn type f kidney cancer, accunting fr apprximately 85% f all malignant kidney tumurs. In RCC, cancerus (malignant) cells develp in the lining f the kidney tubules and grw int a mass called a tumur. Like many ther cancers, the grwth begins small and grws larger ver time. RCC typically grws as a single mass. Hwever, there are cases where a kidney may cntain mre than ne tumur, r tumurs are fund in bth kidneys at the same time. Types f Renal Cell Carcinma (RCC) There are five main types f renal cell carcinma that are identified by examining the tumur under a micrscpe: clear cell, papillary, chrmphbe, cllecting duct and unclassified. Clear Cell RCC - Clear Cell RCC is the mst cmmn frm f renal cell carcinma, accunting fr abut 80% f peple with kidney cancer. When viewed under a micrscpe, the individual cells that make up clear cell renal cell carcinma appear very pale r clear. Papillary RCC - Papillary RCC is the secnd mst cmmn type - abut 10% t 15% f peple have this frm. These cancers frm little finger-like prjectins (called papillae). Chrmphbe RCC - The third mst cmmn frm f renal carcinma is chrmphbe RCC, accunting fr abut 5% f cases. Like clear cell carcinma, the cells f these cancers are als pale, but are much larger and have certain ther distinctive features. Cllecting Duct RCC - The rarest frm f RCC is cllecting duct renal carcinma. The majr characteristic f cllecting duct RCC is that the cancer cells can frm irregular tubes. Unclassified RCC - Abut 5% f renal cancers are unclassified because their appearance des nt fit int any f the ther categries. Recent data suggests that clear cell RCC has a slightly wrse prgnsis as cmpared t papillary r chrmphbe cell RCC. Hwever, the majrity f lw stage tumurs, regardless f cell type, can be cured with surgical resectin. Onccytma is usually a benign lesin with an extremely lw chance f spreading. Spindle cell types, r sarcmas, tend t grw and January 2016 Page 7

8 spread mre quickly than the ther kinds f renal cell carcinma. It can be assciated with any f the subtypes mentined, and this subtype is a sign f a pr prgnsis. Other Types f Cancerus Kidney Tumurs RCC accunts fr abut 90% f malignant kidney tumurs. Less cmmn types f cancerus tumurs include transitinal cell carcinmas, Wilms tumurs and renal sarcmas. Transitinal Cell Carcinma: Abut 5% t 10% f all kidney tumurs are transitinal cell carcinmas, als knwn as urthelial carcinmas. Transitinal cell carcinmas begin in the renal pelvis (the junctin f ureter and kidney). Under the micrscpe, transitinal cell carcinmas lk like bladder cancer cells and act very much like bladder cancer. Studies have shwn that, like bladder cancer, these cancers are linked t cigarette smking and ccupatinal expsures t certain cancer-causing chemicals. The signs and symptms f transitinal cell carcinma are typically the same as with renal cell carcinma - bld in the urine and, smetimes, back pain. Transitinal cell carcinmas are usually treated by surgically remving the entire kidney and the ureter, as well as the sectin f the bladder where the ureter is attached. Chemtherapy and radiatin therapy are ften used in additin t surgery, depending n hw much cancer is fund. As with RCC, with early stage transitinal cell carinmas, there are several treatments. If a patient has early transitinal cell carcinma, there are several treatment ptins available. There are different ways t surgically treat early disease. Newer surgical techniques are als being studied. Patients shuld talk with their surgen and be aware f their ptins and the benefits and risks f thse ptins. Abut 90% f transitinal cell carcinmas f the kidney are curable if they are fund early enugh. The chances fr cure drp dramatically if the tumur has grwn int the ureter wall, r if it has a mre aggressive (high-grade) appearance when viewed under the micrscpe. Wilms Tumur - Abut 5% t 6% f all kidney cancers are Wilms tumurs. This type f cancer is almst always fund in children and is extremely rare amng adults. Renal Sarcma - Renal sarcmas are a rare type f kidney cancer (less than 1% f all kidney tumurs) that begins within the kidney's cnnective tissue. Benign (Nn-Cancerus) Kidney Tumurs Sme types f kidney tumurs (including renal cell adenmas, renal nccytmas and angimylipmas) d nt usually spread (metastasize) t ther parts f the bdy, althugh they can still grw and cause prblems. Renal Adenma - Renal adenmas are very small, slw grwing, benign tumurs that, under a micrscpe, lk a lt like lw-grade renal cell carcinmas. In rare cases, tumurs first thught t be renal adenmas may turn ut t be small renal cell carcinmas. Onccytma - Onccytmas are a type f benign kidney tumur that can smetimes grw quite large. Because nccytmas d nt nrmally metastasize t ther rgans, remving the kidney can ften prduce a cure. January 2016 Page 8

9 Angimylipma - Angimylipmas are anther rare benign kidney tumur. They ften develp in peple with tuberus sclersis (a disease charachterized by several bumps n the skin, seizures, mental retardatin, and cysts in the kidneys, liver and pancreas). (UCLA Health System) Stages f Kidney Cancer A staging system is a standardised way in which the cancer care team describes the extent f the cancer. The mst cmmnly used staging system is that f the American Jint Cmmittee n Cancer (AJCC), smetimes als knwn as the TNM system. The TNM system describes 3 key pieces f infrmatin: T indicates the size f the main (primary) tumur and whether it has grwn int nearby areas. N describes the extent f spread t nearby (reginal) lymph ndes. Lymph ndes are small bean-shaped cllectins f immune system cells that are imprtant in fighting infectins. M indicates whether the cancer has spread (metastasized) t ther rgans f the bdy. (The mst cmmn sites f spread are t the lungs, bnes, liver, and distant lymph ndes.) Numbers r letters appear after T, N, and M t prvide mre details abut each f these factrs. The numbers 0 thrugh 4 indicate increasing severity. The letter X means cannt be assessed because the infrmatin is nt available. T categries fr kidney cancer TX: The primary tumur cannt be assessed (infrmatin nt available). T0: N evidence f a primary tumur. T1: The tumur is nly in the kidney and is 7 cm T1a: The tumur is 4 cm acrss r smaller and is nly in the kidney. T1b: The tumur is larger than 4 cm but nt larger than 7 cm acrss and is nly in the kidney. T2: The tumur is larger than 7 cm acrss but is still nly in the kidney. T2a: The tumur is mre than 7 cm but nt mre than 10 cm acrss and is nly in the kidney T2b: The tumur is mre than 10 cm acrss and is nly in the kidney T3: The tumur is grwing int a majr vein r int tissue arund the kidney, but it is nt grwing int the adrenal gland (n tp f the kidney) r beynd Gerta's fascia (the fibrus layer that surrunds the kidney and nearby fatty tissue). T3a: The tumur is grwing int the main vein leading ut f the kidney (renal vein) r int fatty tissue arund the kidney T3b: The tumur is grwing int the part f the large vein leading int the heart (vena cava) that is within the abdmen. T3c: The tumur has grwn int the part f the vena cava that is within the chest r it is grwing int the wall f that bld vessel (the vena cava). T4: The tumur has spread beynd Gerta's fascia (fibrus layer that surrunds the kidney and nearby fatty tissue). The tumur may have grwn int the adrenal gland (n tp f the kidney). January 2016 Page 9

10 N categries fr kidney cancer NX: Reginal (nearby) lymph ndes cannt be assessed (infrmatin nt available). N0: N spread t nearby lymph ndes. N1: Tumur has spread t nearby lymph ndes. M categries fr kidney cancer M0: There is n spread t distant lymph ndes r ther rgans. M1: Distant metastasis is present; includes spread t distant lymph ndes and/r t ther rgans (such as the lungs, bnes, r brain) (American Cancer Assciatin). Stage gruping Once the T, N, and M categries have been assigned, this infrmatin is cmbined t assign an verall stage f I, II, III, r IV. The stages identify cancers that have a similar prgnsis and thus are treated in a similar way. Patients with lwer stage numbers tend t have a better prgnsis. Stage I: T1, N0, M0 The tumur is 7 cm acrss r smaller and is nly in the kidney (T1). There is n spread t lymph ndes (N0) r distant rgans (M0). Stage II: T2, N0, M0 The tumur is larger than 7 cm acrss but is still nly in the kidney (T2). There is n spread t lymph ndes (N0) r distant rgans (M0). Stage III: Either f the fllwing: T3, N0, M0: The tumur is grwing int a majr vein (like the renal vein r the vena cava) r int tissue arund the kidney, but it is nt grwing int the adrenal gland r beynd Gerta's fascia (T3). There is n spread t lymph ndes (N0) r distant rgans (M0). T1 t T3, N1, M0: The main tumur can be any size and may be utside the kidney, but it has nt spread beynd Gerta's fascia. The cancer has spread t nearby lymph ndes (N1) but has nt spread t distant lymph ndes r ther rgans (M0). Stage IV: Either f the fllwing: T4, any N, M0: The main tumur is grwing beynd Gerta's fascia and may be grwing int the adrenal gland n tp f the kidney (T4). It may r may nt have spread t nearby lymph ndes (any N). It has nt spread t distant lymph ndes r ther rgans (M0). Any T, Any N, M1: The main tumur can be any size and may have grwn utside the kidney (any T). It may r may nt have spread t nearby lymph ndes (any N). It has spread t distant lymph ndes and/r ther rgans (M1) (American Cancer Assciatin; Natinal Cancer Institute). January 2016 Page 10

11 Hw Kidney Cancer Spreads Thrugh the Bdy In the event f kidney cancer spreading t ther parts f the bdy, it wuld mst prbably spread as indicated belw: Cancer Type: Bladder Breast Cln Clrectal Kidney Lung Melanma Ovary Pancreas Prstate Stmach Thyrid Uterus Nn-melanma skin cancer (Natinal Cancer Institute) Main Sites f Metastasis (Spread) Bne, liver, lung Bne, brain, liver, lung Liver, lung Liver, lung, peritneum (lining f abdmen) Adrenal gland, bne, brain, liver, lung Adrenal gland, bne, brain, liver, ther lung Bne, brain, liver, lung, skin, muscle Liver, lung, peritneum (lining f abdmen) Liver, lung, peritneum (lining f abdmen) Adrenal gland, bne, liver, lung Liver, lung, peritneum (lining f abdmen), varies Bne, liver, lung Bner, liver, lung, peritneum (lining f abdmen), vagina Very rare: lymph ndes, lung, bne (if in head/neck regin) Treatment f Kidney Cancer Cmmn treatment ptins fr peple with kidney cancer are surgery, targeted therapy, and bilgical therapy. A patient may receive mre than ne type f treatment. Treatment depends mainly n the fllwing: The size f the tumur Whether the tumur has invaded tissues utside the kidney Whether the tumur has spread t ther parts f the bdy Age and general health At any stage f disease, supprtive care is available t cntrl pain and ther symptms, t relieve the side effects f treatment and t ease emtinal cncerns. Fr example, sme peple with kidney cancer may need t have radiatin therapy t relieve pain r certain ther prblems. Surgery Surgery is the mst cmmn treatment fr peple with kidney cancer. The type f surgery depends n the size and stage f the cancer, whether the patient has tw kidneys, and whether cancer was fund in bth kidneys. The patient and his/her surgen can talk abut the types f surgery and which may be right: Remving all f the kidney (radical nephrectmy): The surgen remves the entire kidney alng with the adrenal gland and sme tissue arund the kidney. Sme lymph ndes in the area may als be remved. January 2016 Page 11

12 Remving part f the kidney (partial nephrectmy): The surgen remves nly the part f the kidney that cntains the tumur. Peple with a kidney tumur that is smaller than a tennis ball may chse this type f surgery. There are tw appraches fr remving the kidney. The surgen may remve the tumur by making a large incisin int the bdy (pen surgery). Or the surgen may remve the tumur by making small incisins (laparscpic surgery). The surgen sees inside the abdmen with a thin, lighted tube (a laparscpe) placed inside a small incisin. Smetimes a rbt is used. The surgen uses handles belw a cmputer display t cntrl the rbt s arms. The surgen may use ther methds f destrying the cancer in the kidney. Fr peple wh have a tumur smaller than 4cm and wh can t have surgery t remve part f the kidney because f ther health prblems, the surgen may suggest: Crysurgery: The surgen inserts a tl thrugh a small incisin r directly thrugh the skin int the tumur. The tl freezes and kills the kidney tumur. Radifrequency ablatin: The surgen inserts a special prbe directly thrugh the skin r thrugh a small incisin int the tumur. The prbe cntains tiny electrdes that kill the kidney cancer cells with heat. It takes time t heal after surgery, and the time needed t recver is different fr each persn. It is cmmn t feel weak r tired fr a while. Pain r discmfrt may be felt fr the first few days. Medicine can help cntrl the pain. Befre surgery, there shuld be discussins abut a plan fr pain relief with the dctr r nurse. After surgery, the dctr can adjust the plan if the patient needs mre pain cntrl. The health care team will watch fr signs f bleeding, infectin, r ther prblems. They will keep track f hw much fluid the patient takes in and hw much urine passes ut f his/her bdy. If ne kidney is remved, the remaining kidney is usually able t d the wrk f bth kidneys. Hwever, if the remaining kidney is nt ding a gd jb cleaning the bld, the patient may need dialysis. Sme peple may need a transplant with a healthy kidney frm a dnr. Arterial Emblisatin fr Kidney Cancer Arterial emblisatin fr kidney cancer is a treatment that may be used when surgery t remve the tumur is nt an ptin. This treatment is meant t shrink the tumur and relieve the symptms f kidney cancer by blcking the flw f bld t the tumur. After underging an arterial emblizatin fr kidney cancer, sme peple may experience back pain r develp a fever. Other side effects f arterial emblizatin can include nausea and vmiting. Targeted Therapy Peple with kidney cancer that has spread may receive a type f drug called targeted therapy. Many kinds f targeted therapy are used fr kidney cancer. This treatment may shrink a kidney tumur r slw its grwth. January 2016 Page 12

13 Usually, the targeted therapy is taken by muth. Patients may feel very tired while taking targeted therapy fr kidney cancer. Other side effects may include diarrhea, nausea, vmiting, sres n the lips r in the muth and high bld pressure. Bilgical Therapy Peple with kidney cancer that has spread may receive bilgical therapy. Bilgical therapy fr kidney cancer is a treatment that may imprve the bdy s natural defence (the immune system respnse) against cancer. The treatments used fr kidney cancer can slw the grwth f tumurs r shrink them. The bilgical therapy is injected intravenusly r under the skin. The treatment may be given at the hspital r a dctr s ffice. Other drugs may be given at the same time t prevent side effects. The side effects differ with the bilgical therapy used, and frm persn t persn. Bilgical therapy cmmnly causes a rash r swelling. Patients may feel very tired during treatment. The treatment may als cause a headache, muscle aches, a fever, r weakness. Raditherapy Renal-cell carcinma is cnsidered t be radi-resistant, but it was recently fund that this ntin might be wrng. During Recent research De Meerleer, et al. (2014) fund that if given in a few (even single) fractins, but at a high fractin dse, steritactic bdy raditherapy becmes increasingly imprtant in the management f renal-cell carcinma, bth in primary settings and in treatment f ligmetastatic disease. There is an established bilgical ratinale fr the radi-sensitivity f renal-cell carcinma t steretactic bdy raditherapy based n the ceramide pathway, which is activated nly when a high dse per fractin is given. Apart frm the direct effect f steretactic bdy raditherapy n renal-cell carcinma, steretactic bdy raditherapy can als induce an abscpal effect (an abscpal effect is a phenmenn in the treatment f metastatic cancer where lcalised irradiatin f a tumur causes nt nly a shrinking f the irradiated tumur but als a shrinking f tumurs far frm the irradiated area), This effect, caused by immunlgical prcesses, might be enhanced when targeted drugs and steretactic bdy raditherapy are cmbined. Therefre, rigrus, prspective randmised trials invlving a multidisciplinary scientific panel are needed urgently, accrding t De Meerleer, et al. Secnd Opinin Befre starting treatment, patients may want a secnd pinin abut the diagnsis, stage f cancer, and treatment plan. Sme peple wrry that the dctr will be ffended if they ask fr a secnd pinin. Usually the ppsite is true. Mst dctrs welcme a secnd pinin. If a patient gets a secnd pinin, the secnd dctr may agree with the first dctr s diagnsis and treatment plan. Or the secnd dctr may suggest anther apprach. Either way, the patient has mre infrmatin and perhaps a greater sense f cntrl. Patients can als feel mre cnfident abut the decisins they make, knwing that they have lked at all f their ptins. It may take sme time and effrt t gather the medical recrds and see anther dctr. In mst cases, it s nt a prblem t take several weeks t get a secnd pinin. The delay in January 2016 Page 13

14 starting treatment usually will nt make treatment less effective. T make sure, patients shuld discuss this delay with their dctr. (Natinal Cancer Institute). Side Effects f Treatment Because treatment may damage healthy cells and tissues, unwanted side effects are cmmn. These side effects depend mainly n the type and extent f the treatment. Side effects may nt be the same fr each persn, and they may change frm ne treatment sessin t the next. Befre treatment starts, the health care team will explain pssible side effects and suggest ways t help the patient manage them. Surgery - It takes time t heal after surgery, and the time needed t recver is different fr each persn. Patients are ften uncmfrtable during the first few days. Hwever, medicine can usually cntrl their pain. Befre surgery, patients shuld discuss the plan fr pain relief with the dctr r nurse. After surgery, the dctr can adjust the plan if mre pain relief is needed. It is cmmn t feel tired r weak fr a while. The health care team watches the patient fr signs f kidney prblems by mnitring the amunt f fluid the patient takes in and the amunt f urine prduced. They als watch fr signs f bleeding, infectin, r ther prblems requiring immediate treatment. Lab tests help the health care team mnitr fr signs f prblems. If ne kidney is remved, the remaining kidney generally is able t perfrm the wrk f bth kidneys. Hwever, if the remaining kidney is nt wrking well r if bth kidneys are remved, dialysis is needed t clean the bld. Fr a few patients, kidney transplantatin may be an ptin. Fr this prcedure, the transplant surgen replaces the patient's kidney with a healthy kidney frm a dnr. Arterial Emblisatin - After arterial emblizatin, sme patients have back pain r develp a fever. Other side effects are nausea and vmiting. These prblems sn g away. Radiatin Therapy - The side effects f radiatin therapy depend mainly n the amunt f radiatin given and the part f the bdy that is treated. Patients are likely t becme very tired during radiatin therapy, especially in the later weeks f treatment. Resting is imprtant, but dctrs usually advise patients t try t stay as active as they can. Radiatin therapy t the kidney and nearby areas may cause nausea, vmiting, diarrhea, r urinary discmfrt. Radiatin therapy als may cause a decrease in the number f healthy white bld cells, which help prtect the bdy against infectin. In additin, the skin in the treated area may smetimes becme red, dry, and tender. Althugh the side effects f radiatin therapy can be distressing, the dctr can usually treat r cntrl them. Bilgical Therapy - Bilgical therapy may cause flu-like symptms, such as chills, fever, muscle aches, weakness, lss f appetite, nausea, vmiting, and diarrhea. Patients als may get a skin rash. These prblems can be severe, but they g away after treatment stps. January 2016 Page 14

15 Chemtherapy - Kidney cancer des nt respnd well t chemtherapy drugs. The side effects f chemtherapy depend mainly n the specific drugs and the amunt received at ne time. In general anticancer drugs affect cells that divide rapidly, especially: Bld cells: These cells fight infectin, help the bld t clt, and carry xygen t all parts f the bdy. When drugs affect bld cells, patients are mre likely t get infectins, may bruise r bleed easily, and may feel very weak and tired. Cells in hair rts: Chemtherapy can cause hair lss. The hair grws back, but smetimes the new hair is smewhat different in clur and texture. Cells that line the digestive tract: Chemtherapy can cause pr appetite, nausea and vmiting, diarrhea, r muth and lip sres. Many f these side effects can be cntrlled with drugs (Rsswell Park Cancer Institute). Reducing the Risk fr Kidney Cancer Taking steps t imprve ne s health may help reduce the risk f kidney cancer. T reduce the risk: Quit smking. If smking, quit. Many ptins fr quitting exist, including supprt prgrams, medicatins and nictine replacement prducts. Cntact CANSA t jin CANSA s e-kickbutt prgramme Eat at least five prtins f vegetables and fresh fruit (in seasn). A variety f fruits and vegetables helps ensure getting all the nutrients ne needs. Replace sme snacks and side dishes with fruits and vegetables this may help ne lse weight as well Maintain a healthy weight. Wrk t maintain a healthy weight. If verweight r bese, reduce the number f calries cnsumed each day and try t exercise mst days f the week Cntrl high bld pressure Reduce r avid expsure t envirnmental txins (May Clinic). Cmplicatins f Kidney Cancer Cmplicatins that have been mentined in varius surces fr Kidney Cancer includes: Metastases (cancer that has spread) t: Lungs Bnes Brain Paraneplastic syndrme Bld clts Cngestive heart failure Plycythaemia Pyrexia (fever) f unknwn rigin AA amylidsis Renal cysts Malignant hepatpathy Haematuria January 2016 Page 15

16 Cutaneus metastasis Renal enlargement (Right Diagnsis). Fllw-up Care After surgery fr early r lcally advanced kidney cancer, the patient will have regular checkups. The first appintment is usually 4 t 6 weeks after ging hme frm hspital. This is t make sure the patient is recvering well frm the peratin. After this, if the risk f cancer cming back is thught t be lw, they patient may nly need fllw up fr 5 years. They might have a chest X-ray every 3 mnths fr the first 2 years, and then every 6 mnths until they reach 5 years. If the risk f cancer cming back is higher patients are usually rdered t underg regular CT scans fr the first 3 years. Things that increase the risk f the cancer cming back include: Having a tumur larger than 5cm acrss Changes in the tumur cells called sarcmatid de-differentiatin Tumur cells at the edge f the tissue that the surgen remved dctrs call this a psitive margin Raised levels in the bld f a chemical called alkaline phsphatase Raised levels in the bld f a chemical called lactate dehydrgenase If all is well after 3 years, the patient is advised t have X-rays every 6 mnths. But this fllw up may cntinue fr life t check fr any sign f the cancer cming back. After surgery fr kidney cancer, the mre time that passes with n sign f it, the smaller the risk f the cancer ever cming back. But there is still a small risk, even after 10 years. What happens at fllw-up appintments The treating dctr will cnduct a physical examinatin and may rder ne r mre f the fllwing tests Bld tests Chest X-ray CT scan Ultrasund scan Fllw-up after crytherapy r radifrequency ablatin In the event f a small kidney cancer treated by crytherapy r radifrequency ablatin, the patient will be advised t attend appintments and scans every 3 t 6 mnths. These are t see whether the cancer has cme back r is grwing. Appintments during bilgical therapy treatment fr advanced kidney cancer In the case f advanced cancer and while n treatment with bilgical therapy, the patient will be advised t attend regular appintments and scans every 3 t 6 mnths. The scans check hw well the treatment is wrking. January 2016 Page 16

17 Between appintments Patients wh have any cncerns r wh are wrried r ntice any new symptms between appintments, must cntact their dctr as sn as pssible (CancerHelp UK). Kidney Cancer Diet Patients with ne healthy remaining kidney can return t a nrmal diet. In general, eating a diet lw in sdium is gd fr the entire bdy, including the kidneys. This is especially recmmended in patients wh have nly ne kidney. Having a kidney stne may prtend pr renal functin, including end-stage renal disease, researchers fund. Even a single kidney stne episde was assciated with a significant increase in the likelihd f adverse renal utcmes including end stage renal disease (ESRD). (Alexander, et al., 2012). Limit prtein intake t 1 gram f prtein per kilgram bdyweight per day, e.g. with a weight f 65kg, limit prtein intake t 65 grams per day Limit the intake f red meat Eat 5 t 6 small meals per day Take in sufficient fluids. Fluid intake shuld be 30ml f fluid per kilgram bdy weight per day. A minimum f 60% f fluid intake shuld be safe, clean water. The daily water intake shuld be 30ml f water per kilgram bdy weight x 0.6 Make sure t take in sufficient calries t maintain ideal bdy weight Limit the intake f sdium. Salt is made up f sdium and chlride. The sdium in salt, when excreted by the kidneys, causes mre calcium t be excreted int the urine. High cncentratins f calcium in the urine cmbine with xalate and phsphrus t frm stnes. Reducing salt intake is preferred t reducing calcium intake Chse fresh fruits and vegetables eat at least 5 prtins f fresh vegetables and fruit (in seasn) daily Avid prcessed and packaged fds D nt add salt at the table Learning the sdium cntent f fds can help cntrl sdium intake. Fd labels prvide infrmatin abut sdium and ther nutrients. Keeping a sdium diary can help a persn limit sdium intake t 2 400mg per day. When eating ut, ask abut the sdium cntent f the fds that are rdered. Sme fds have such large amunts f sdium that a single serving prvides a majr prtin f ne s daily sdium allwance. Fds that cntain high levels f sdium include ht dgs canned sups and vegetables prcessed frzen fds cld meats fast fds Check fd labels fr ingredients such as hidden sdium. Check fr: mnsdium glutamate (MSG) sdium bicarbnate, the chemical name fr baking sda baking pwder, which cntains sdium bicarbnate and ther chemicals disdium phsphate sdium alginate sdium nitrate r nitrite January 2016 Page 17

18 Limit (nt avid) intake f ptassium even thugh ptassium is an essential nutrient used t maintain fluid and electrlyte balance in the bdy. Check fd labels. Ptassium-rich fds include: Avcad Paprika Cca Chclates Dried apricts, prunes, Zante currents and raisins Mst nuts Seeds (pumpkin, squash, sunflwer and flax) Fish Beans Dates Limit the intake f phsphrus. Fds rich in phsphrus include: Liver Beans Chclates Yghurt Milk Cheese Avid salt substitutes, many f which cntain ptassium Flavur fds with garlic, herbs, lemn juice and pepper, instead f salt and sy sauce Avid alchl Prevent kidney stne frmatin. T prevent kidney stne frmatin, avid the intake f xalates. Oxalates are di-anins with a frmula C2O42-, als written as (COO)22-. Many metal ins frm insluble precipitates with xalates, a gd example being calcium xalate, the primary cnstituent f the mst cmmn kind f kidney stne. The fllwing are xalate-rich plants and fd that shuld be avided: Srrel and related plants Rhubarb Buckwheat - a cereal grain that is related t rhubarb and srrel Black pepper Parsley Pppy seed [Picture Credit: Amaranth]. January 2016 Page 18

19 Amaranth - a mderately tall, brad-leafed, bushy type f plant that grws abut tw metres in height and prduces a brightly clured flwery head cntaining a very large number f seeds. (Amaranth plants can prduce as many as seeds.) These seeds are the amaranth grains fund in amaranth cereal and flur. Amaranth is a member f the Chenpdiaceae family f plants and therefre is a relative f beets, Swiss chard, spinach, and quina. Spinach Chard - a leafy green vegetable ften used in Mediterranean cking. While the leaves are always green, chard stalks vary in clur. [Picture Credit: Beetrt Family]. Beets are plants f the Chenpdiaceae family which is nw included in Amaranthaceae family. It is best knwn in its numerus cultivated varieties, the mst well knwn f which is the rt vegetable knwn as the beetrt r garden beet. Hwever, ther cultivated varieties include the leaf vegetable chard, as well as the rt vegetable sugar beet, which is imprtant in the prductin f table sugar, and mangelwurzel, which is a fdder crp. The rts are mst cmmnly deep red-purple in clur, but cme in a wide variety f ther shades, including glden yellw and red-and-white striped. Cca Chclates Mst nuts Mst berries Leaves f the tea plant ( black tea) Avid raw fish - including sushi and sashimi (a Japanese delicacy cnsisting f very fresh raw meat r fish sliced int thin pieces), and undercked finfish and shellfish (including ysters, clams, mussels, and scallps) as they are mre likely t cntain parasites r bacteria than cked fish. [Picture Credit: Sashimi Platter]. (ehw; Natinal Kidney and Urlgical Diseases Infrmatin Clearing Huse). January 2016 Page 19

20 Abut Clinical Trials Clinical trials are research studies that invlve peple. These studies test new ways t prevent, detect, diagnse, r treat diseases. Peple wh take part in cancer clinical trials have an pprtunity t cntribute t scientists knwledge abut cancer and t help in the develpment f imprved cancer treatments. They als receive state-f-the-art care frm cancer experts. Types f Clinical Trials Cancer clinical trials differ accrding t their primary purpse. They include the fllwing types: Treatment - these trials test the effectiveness f new treatments r new ways f using current treatments in peple wh have cancer. The treatments tested may include new drugs r new cmbinatins f currently used drugs, new surgery r radiatin therapy techniques, and vaccines r ther treatments that stimulate a persn s immune system t fight cancer. Cmbinatins f different treatment types may als be tested in these trials. Preventin - these trials test new interventins that may lwer the risk f develping certain types f cancer. Mst cancer preventin trials invlve healthy peple wh have nt had cancer; hwever, they ften nly include peple wh have a higher than average risk f develping a specific type f cancer. Sme cancer preventin trials invlve peple wh have had cancer in the past; these trials test interventins that may help prevent the return (recurrence) f the riginal cancer r reduce the chance f develping a new type f cancer. Screening - these trials test new ways f finding cancer early. When cancer is fund early, it may be easier t treat and there may be a better chance f lng-term survival. Cancer screening trials usually invlve peple wh d nt have any signs r symptms f cancer. Hwever, participatin in these trials is ften limited t peple wh have a higher than average risk f develping a certain type f cancer because they have a family histry f that type f cancer r they have a histry f expsure t cancer-causing substances (e.g., cigarette smke). Diagnstic - these trials study new tests r prcedures that may help identify, r diagnse, cancer mre accurately. Diagnstic trials usually invlve peple wh have sme signs r symptms f cancer. Quality f life r supprtive care - these trials fcus n the cmfrt and quality f life f cancer patients and cancer survivrs. New ways t decrease the number r severity f side effects f cancer r its treatment are ften studied in these trials. Hw a specific type f cancer r its treatment affects a persn s everyday life may als be studied. Where Clinical Trials are Cnducted Cancer clinical trials take place in cities and twns in dctrs ffices, cancer centres and ther medical centres, cmmunity hspitals and clinics. A single trial may take place at ne r tw specialised medical centres nly r at hundreds f ffices, hspitals, and centres. Each clinical trial is managed by a research team that can include dctrs, nurses, research assistants, data analysts, and ther specialists. The research team wrks clsely with ther health prfessinals, including ther dctrs and nurses, labratry technicians, pharmacists, dieticians, and scial wrkers, t prvide medical and supprtive care t peple wh take part in a clinical trial. January 2016 Page 20

21 Research Team The research team clsely mnitrs the health f peple taking part in the clinical trial and gives them specific instructins when necessary. T ensure the reliability f the trial s results, it is imprtant fr the participants t fllw the research team s instructins. The instructins may include keeping lgs r answering questinnaires. The research team may als seek t cntact the participants regularly after the trial ends t get updates n their health. Clinical Trial Prtcl Every clinical trial has a prtcl, r actin plan, that describes what will be dne in the trial, hw the trial will be cnducted, and why each part f the trial is necessary. The prtcl als includes guidelines fr wh can and cannt participate in the trial. These guidelines, called eligibility criteria, describe the characteristics that all interested peple must have befre they can take part in the trial. Eligibility criteria can include age, sex, medical histry, and current health status. Eligibility criteria fr cancer treatment trials ften include the type and stage f cancer, as well as the type(s) f cancer treatment already received. Enrlling peple wh have similar characteristics helps ensure that the utcme f a trial is due t the interventin being tested and nt t ther factrs. In this way, eligibility criteria help researchers btain the mst accurate and meaningful results pssible. Natinal and Internatinal Regulatins Natinal and internatinal regulatins and plicies have been develped t help ensure that research invlving peple is cnducted accrding t strict scientific and ethical principles. In these regulatins and plicies, peple wh participate in research are usually referred t as human subjects. Infrmed Cnsent Infrmed cnsent is a prcess thrugh which peple learn the imprtant facts abut a clinical trial t help them decide whether r nt t take part in it, and cntinue t learn new infrmatin abut the trial that helps them decide whether r nt t cntinue participating in it. During the first part f the infrmed cnsent prcess, peple are given detailed infrmatin abut a trial, including infrmatin abut the purpse f the trial, the tests and ther prcedures that will be required, and the pssible benefits and harms f taking part in the trial. Besides talking with a dctr r nurse, ptential trial participants are given a frm, called an infrmed cnsent frm, that prvides infrmatin abut the trial in writing. Peple wh agree t take part in the trial are asked t sign the frm. Hwever, signing this frm des nt mean that a persn must remain in the trial. Anyne can chse t leave a trial at any time either befre it starts r at any time during the trial r during the fllw-up perid. It is imprtant fr peple wh decide t leave a trial t get infrmatin frm the research team abut hw t leave the trial safely. The infrmed cnsent prcess cntinues thrughut a trial. If new benefits, risks, r side effects are discvered during the curse f a trial, the researchers must infrm the participants s they can decide whether r nt they want t cntinue t take part in the trial. January 2016 Page 21