Daniel George, MD: When I see a patient with kidney cancer who is new to our clinic, I usually start by helping the patient understand where they stand in terms of this disease. What stage are they? Is this disease that’s contained within the kidney—stage 1, 2, or even stage 3 cancer? If so, that’s disease that we’re going to primarily treat with surgery. The surgery is going to be to remove the tumor. It’s either going to be to remove just the tumor or the entire kidney. Sometimes we see spread into a vein or into a lymph node.
When we do that, and after we do that, we’re going to see the patient back to talk about next steps. We’re going to do staging. We’re going to look with a CAT scan for any sign of the cancer recurring. If they’re diagnosed with stage 3 disease or there is lymph node involvement, we may talk with that patient about additional therapy. We call this adjuvant therapy. Adjuvant therapy may be administered through a clinical trial, or it may be a standard of care option. Those are the kinds of things that we’ll talk about for those patients.
For patients that present with stage 4 cancer—disease that’s now spread to another part of the body—there’s a little bit of a different approach. If it looks reasonable—most of the cancer is still contained within the kidney, and the disease in the other parts of the body is small volume and is not very symptomatic—we’ll start by taking out the kidney. Even though that won’t cure the patient, it is associated with a long-term benefit—a survival benefit and a symptom benefit. This may also correspond with a change in the course of the disease. And most of the patients, under that circumstance, will recover from that. Then, we’ll be able to start another therapy.
For other patients, we’ll start therapy first. That therapy is what we call systemic therapy—treatment that goes through the body. It can be either given as a pill or as an intravenous therapy. The pill therapies tend to be therapies that we have patients take every day. Sometimes we have them take them continuously; sometimes we’ll take breaks. We monitor patients closely for side effects. The most common side effects with the pill therapy—from sunitinib, cabozantinib, or pazopanib—would be things like high blood pressure, fatigue, or diarrhea; occasionally, some blistering of sores on the hands or feet may occur.
These are side effects that patients will need to tell us about. We’ll help them manage these things. There are some remedies that we can use to help manage blood pressure or diarrhea and even help with the hands and the feet. Many times, we’ll have to change or modify the dose.
For the intravenous therapies that we use, there is a little bit of a different strategy. For the most part, these are medicines that are going to target the immune system. The side effects are different. They still may be diarrhea and fatigue, but we’re going to manage them differently. They’re inflammatory. They are less driven by the actual treatment and more driven by the immune system. So, we use drugs to dampen the immune system—things like steroids or anti-inflammatories.
Again, it’s really important to talk with your doctor. These are serious consequences—they can spiral out of control. You can’t suppress this information. You can’t stress enough the management of side effects and telling your team how to do that.
Most importantly, you need to have a team. Medicine is very much a team sport. I don’t practice alone. I have colleagues. I have nurse practitioners and physician assistants. We have pharmacists. We have nurses that help us with seeing the patient, with managing side effects, with educating the patient, with follow-up, with triage and emergency calls, and with coverage. We have social work. We have dietitians. We have exercise physiologists. These are all people that play a role in helping from the health system side.
On the family side, you can’t do this alone. You need support. Family is probably the most obvious support mechanism. Close friends, church structures, and other community support are also important. In cancer, I can’t stress enough that you recognize who your team is and have trust in them. The health system has got to be a part of that, but it’s not the whole part.
At Duke, we really work to talk to people about this. We work to identify all of the players in this. We really communicate with everybody, to do the best we can for patients. Regardless of what treatment they’re on or what stage they are, these are all critical aspects to having the best outcomes.