Should the Cancerous Kidney Be Surgically Removed in Stage 4 Disease?

Renal cell cancer is the 10th most common cancer in the United States. Despite increasing public awareness about cancer and advances in imaging methods, of every 10 kidney cancers, 3 are diagnosed at the fourth stage. Today, apart from a small number of patients, there is no chance of cure, that is, recovery through treatment and complete freedom from disease, in stage 4 kidney cancer. The aim of treatments is to extend the patient’s life while improving quality of life.

Before 2005, survival in fourth-stage kidney cancer, which we treated with chemotherapy and older-generation immunotherapy drugs, was almost less than 6 months. While treating patients with these treatments of very limited benefit, surgically removing the cancerous kidney in patients at the metastatic stage was a practice we preferred because it contributed to survival.

As is known, in many types of cancer, removing the primary tumor surgically is not preferred if the disease has reached the fourth stage. In a patient, tumor burden-reducing surgery (cytoreductive surgery) , meaning surgically removing the organ from which the disease originates together with its tumor even though we cannot remove all disease from the body, is beneficial in a few types of cancer. One of these was renal cell cancer. After very useful drugs (targeted therapies) entered use in renal cell cancer treatment at the end of 2005, whether the cancerous kidney should be removed remained a puzzle. With the approval of new-generation immunotherapies for kidney cancer after targeted therapies, success in this field increases every day. During this positive process, we learned the answer to the question we had wondered about for more than 10 years in metastatic kidney cancer from the study by Hanna and colleagues published in the September 2016 issue of the Journal of Clinical Oncology.

Using national cancer data, kidney cancer patients treated with targeted drugs between 2006 and 2013, totaling 15.390 patients, were reviewed retrospectively, and 5.374 were found to have had their cancerous kidneys surgically removed. Among patients treated with targeted drugs, average survival was 17 months in the group whose cancerous kidneys were removed surgically, while overall survival was found to be 7.7 months in patients who did not undergo surgery. This survival advantage is extremely striking. The results of this study have been highly informative for our daily practice.

The question that has always occupied our minds in daily practice, “Does removing our patients’ cancerous kidney provide benefit alongside targeted therapies and new-generation immunotherapies?” has now been answered.

The information we have gained from this study is that, in our patients with metastatic kidney cancer, if there is no condition preventing surgery, surgical removal of their cancerous kidney at the start of treatment or at an appropriate time will be in our patients’ favor.