MEN'S HEALTH MATTERS:The incidence of kidney cancer has increased since the early 1990s writes THOMAS LYNCH
Q I have had some abdominal discomfort recently and my doctor arranged for me to have an ultrasound scan of my abdomen to see if I had gallstones. The scan picked up a small kidney cancer. Is this common, and what should I expect?
A The incidence of kidney cancer (renal cell carcinoma) in Ireland in 2007 was 7.3 cases per 100,000 in women and 12.4 cases per 100,000 in men. Similar to the United States, Irish doctors have seen an increase in the incidence of kidney cancer since the early 1990s.
There are many reasons for the increase which is also seen in other cancers. More people are undergoing abdominal scans for investigation of non-related complaints. This leads to a diagnosis of kidney cancer in patients who actually have no symptoms of kidney cancer. These cases are called incidental kidney cancers.
A minority of patients, however, can present complaining of blood in their urine, abdominal or side pain, or a palpable mass (lump). Occasionally your general practitioner may notice a trace of blood in your urine during a routine check-up.
With the majority of kidney cancers diagnosed nowadays being incidental, there has been an increase in the number and a change in the features of newly diagnosed kidney cancers. Incidental cancers are generally smaller than those that cause symptoms, and tend not to have spread to anywhere else in the body.
Before your urologist recommends a treatment plan for you, they will need to assess your overall medical condition. Blood tests to check your blood count, kidney and liver function will be performed.
A urine test to check for blood or infection will also be undertaken. A CT scan of your abdomen and chest will be performed. These scans check the size, exact location of the cancer within the kidney, the presence of extension into the draining veins and also for the spread of disease.
Whereas a diagnosis of kidney cancer can quite reliably be made on imaging, the actual type of kidney cancer which you have cannot be known until the cancer is removed. Once removed, the cancer is examined by a pathologist and a definitive diagnosis can then be made.
The size, location and potential presence of an extension into the draining vein of your kidney cancer will determine its method of removal. Dependent on these features, your urologist will discuss the viability of a partial or a total nephrectomy (removal of the kidney). A partial nephrectomy involves removal of the cancer with preservation of the neighbouring normal kidney tissue. A total nephrectomy involves removal of the entire kidney.
Both of the above operations may be performed via the traditional open surgical method or via minimally invasive laparoscopic (keyhole surgery) methods. In general, small kidney cancers which are located in the periphery of the kidney are suitable for partial nephrectomy, whereas large centrally placed cancers require total nephrectomy.
Occasionally patients may be offered arterial embolisation or radiotherapy as treatment options of their cancer. However, surgery is performed in the majority of cases. Chemotherapy has, to date, been of limited benefit in kidney cancer. Your doctor shall discuss the most suitable treatment option with you.
Q I am 68 years old and have recently been diagnosed with prostate cancer and read about a new treatment called High Intensity Focused Ultrasound. What is this treatment and would you recommend it?
A High Intensity Focused Ultrasound (HIFU) is known as a minimally invasive therapy and, along with other options such as radiofrequency ablation, cryosurgery (freezing the prostate) and photodynamic therapy (light treatment), offers a middle-ground approach.
It has a potentially reduced risk of adverse effects compared to radical treatment and is more proactive than active surveillance. However, these therapies are in various stages of research and development and their use in clinical practice is limited.
HIFU involves focusing high-energy ultrasound waves on the target cancerous tissues, which causes them to die. The probe that emits the ultrasound waves is inserted into the rectum and a cooling balloon around the probe protects the surrounding healthy tissue.
After the procedure, catheterisation (tube to drain urine from the bladder) is required for a short period of time.
At present, the main limitation of this particular procedure is that there is little information available on longer-term outcomes. However, it will be some time before this could become a standard treatment option and the outcomes of much larger numbers of men who have had this treatment are needed.
The best-quality evidence would come from randomised controlled trials that compared HIFU to standard options (surgery, radiotherapy or active surveillance) and other minimally invasive options.
Headlines in the newspapers recently like “Prostate cancer treatment more successful than surgery” are not accurate at present as the longer-term effects on survival and quality of life are unknown.
You must be made aware that uncertainties exist and that the alternative treatment options have a proven track record.
This weekly column is edited by Thomas Lynch, consultant urological surgeon, St James’s Hospital, Dublin with a contribution from Dr Deirdre Fanning, urology registrar, St James’s Hospital, Dublin