Sandy Liu, MD: Regarding front-line surgical resection options, if patients are healthy enough and they don’t have any symptoms, I tend to favor surgery first. Even with metastatic advanced stage 4 disease, I tend to refer them to my urologist to consider a nephrectomy. Studies have shown that if you get the primary kidney out before starting any kind of therapy, patients tend to do well and live longer. In terms of me prescribing front-line surgical resection to everyone, I do if I can see that they’re able to handle it. If they’re weak or they have a lot of symptoms, I generally tend to start therapy. If they get strong enough, then I refer them to surgery.
The way I describe prognostic outcomes of surgery to patients is basically telling them that surgery is recommended if they’re able to handle it. If they’re strong enough and able to handle it, I would generally refer them to my urologist. To do surgery upfront and then systemic therapy is much better than waiting and not doing the surgery. So, generally, I tend to favor surgery. I tell patients that it yields a better survival benefit if they undergo upfront surgery.
For patients who I recommend for surgery, to prepare for surgery, I generally tell them to not lose weight—that’s very important—to get their nutritional status up, to stay physically active, to make sure their blood pressure is well-controlled, to make sure that they don’t have any active disease in terms of their diabetes and that their other problems are very well-controlled, to meet with the surgeon, to make sure that they’re not on any blood thinners that would cause increased bleeding, and to just minimize the risks of surgery. I get them strong and healthy enough to undergo surgery.
The test I order after front-line surgical resection is a scan, a whole-body scan, to make sure that the surgery removed all the tumor, that there are no complications from surgery, and that they’re healing well and there’s no evidence of disease—the surgeon removed the primary tumor, and nothing is left behind. If nothing is left behind, I would do the whole-body scan every 3 months for the first 2 to 3 years to make sure that the cancer does not come back.