Active Surveillance for Kidney Cancer
This is the least invasive treatment option. During active surveillance the patient and urologist agree to observe the tumor by obtaining regular imaging. For some patients, no intervention is ever needed while for others a "trigger for intervention" is reached and therapy is instituted.
Patients with tumors less than 3cm in size are ideal candidates for active surveillance due to the low likelihood that the tumor will spread during observation.
In addition to a small tumor, several patient factors make this an attractive option:
- Patients with poor kidney function. Since any intervention on the kidney can cause further deterioration of kidney function, these patients may be better off selecting active surveillance. In some patients, further decline in kidney function puts the patient at risk of needing dialysis. Dialysis, while life saving, may be associated with poor outcomes and a low quality of life. Ask your doctor about your creatinine level which is an indicator of kidney function (normal is < 1.5 mg/dl).
- Patients with hereditary forms of kidney cancer. This includes patients with Von-Hippel-Lindau (VHL), Birt-Hogg-Dube (BHD), or other conditions in which patients are at risk of having multiple tumors on both sides. These tumors are typically placed on active surveillance until they reach 3cm or larger.
- Patients who have drug eluting heart stents and need to be on a blood thinner. Kidney surgery/intervention can result in severe bleeding in these patients and thus a period of active surveillance until they can come off the blood thinners may be helpful to avoid a potential serious complications.
- Elderly patients who are medically fragile . Since the risk that the small kidney tumor spreads is low, in patients with a short life expectancy (<10years) a discussion regarding active surveillance may be prudent. Many of these patients die WITH the kidney tumor rather than OF the kidney tumor.
- Patients who are experiencing or recovering from an active serious medical problem. A period of active surveillance until things stabilize should be entertained.
- Patients who are extremely anxious about having surgery or do not wish to have treatment .
What are the so-called "triggers for intervention"?
The most common trigger for intervention currently is demonstrated tumor growth. Change in the patient condition could also trigger intervention. For example, a patient who was having a heart attack when their 2.5cm kidney tumor was discovered has now recovered 1 year later and is fit for surgery. This now triggers an intervention.
What does active surveillance entail?
Typically we advocate imaging every 3-6 months for 2 years then every 6-12 months annually. The initial evaluation should include a complete staging evaluation (blood work, chest/abdomen/pelvis imaging) to exclude the possibility that the disease has already spread. We prefer CT or MRI for the initial evaluation and then alternate between CT, MRI, and Ultrasound to minimize radiation to the patient and to comprehensively evaluate the tumor. The exact protocol is customized to the patient.
Can the tumor spread while on active surveillance?
The answer to this is unfortunately YES. However, for a well-selected patient the risk of this occurring on surveillance is very low (<2%). Each patient and tumor are unique and this risk should be discussed with your urologist.
In patients who elect for delayed intervention, are the results compromised?
A recent study* by Johns Hopkins urologists showed that a period of active surveillance did not alter results. In this study, patients delayed treatment of their small kidney mass by over 1 year. All were eventually treated with minimally invasive surgery successfully.
*(Rais-Bahrami S, Guzzo TJ, Jarrett TW, Kavoussi LR, Allaf ME. Incidentally discovered renal masses: oncological and perioperative outcomes in patients with delayed surgical intervention. BJU Int. 2009 May;103(10):1355-8)
Does Johns Hopkins have an active surveillance program for kidney tumors?
Yes. Pioneers in this area, Johns Hopkins urologists have a formal program for observation of kidney tumors in the appropriate patient. The program involves regular check-ups and filling out questionnaires regarding quality of life, anxiety, and general well being. This helps with decision-making throughout the surveillance process. In the event an intervention is eventually selected, the kidney cancer expert urologist can then help tailor the best therapy for the patient.
How do I enroll in active surveillance at Johns Hopkins?
After a detailed evaluation by one of our experts, the patient signs a consent form and is enrolled in our formal prospective registry for active surveillance. We will follow the patient with regular questionnaires evaluating his/her quality of life and review all imaging at regular intervals to optimize their. Each patient has a personalized schedule. For example a 90 year old patient with a 1cm tumor may want to be imaged once every year. In contrast a 45 year old patient with a 2.8cm tumor will likely be imaged at more frequent intervals.