Kidney cancer: diagnosis and management

  • NICE guideline
  • NG256
  • Published: 
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Managing advanced renal cell carcinoma

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Healthcare professionals should follow our general guidelines for people delivering care:

The following recommendations apply to people with advanced renal cell carcinoma (RCC), unless metastatic RCC is specified.

1.12 Referring people with advanced RCC

1.12.1

Refer people with advanced RCC to a uro-oncology multidisciplinary team with relevant expertise in managing kidney cancer (for example, a radiologist, pathologist, oncologist and urologist with speciality in kidney cancer surgery).

1.12.2

Refer people with metastatic RCC to a specialist multidisciplinary team, based on where the disease has metastasised to in the body (such as the brain, spine or lung) when additional specialist input or skill is needed.

See also the section on recognising spinal metastases or metastatic spinal cord compression (MSCC) in NICE's guideline on spinal metastases and MSCC and the section on investigation of suspected brain metastases in NICE's guideline on brain tumours (primary) and brain metastases in over 16s.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on referring people with advanced RCC.

Full details of the evidence and the committee's discussion are in evidence review H: management of advanced renal cell carcinoma using non-pharmacological interventions.

1.13 Risk prediction tools for metastatic RCC

1.13.1

Consider using the International Metastatic Renal Cell Carcinoma Database Consortium (IMDC version 1) to predict overall survival when deciding about treatment options for people with metastatic RCC.

1.13.2

Do not rely on the IMDC alone, and always use it with clinical judgement, when deciding about future treatment options, taking into account that the usefulness and accuracy of the tool is more uncertain:

1.13.3

If relevant NICE technology appraisal guidance or NHS clinical commissioning criteria for RCC use a particular risk prediction tool that is not the IMDC to determine eligibility for systemic anticancer therapy (SACT) for people with metastatic RCC, use that tool instead of the IMDC if SACT is indicated.

1.13.4

Record the risk score clearly in the person's clinical records before any decisions about future treatment options are made.

1.13.5

When using the IMDC risk prediction tool for people with metastatic RCC, share with them:

  • the name of the tool

  • what the tool has been used for

  • that most of the data supporting the tool comes from clear cell RCC, and so the usefulness and accuracy of the tool in rarer RCC subtypes is more uncertain

  • what the results mean for their potential treatment options.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on risk prediction tools for metastatic RCC.

Full details of the evidence and the committee's discussion are in evidence review L: risk prediction tools for metastatic renal cell carcinoma.

1.14 Non-pharmacological management of metastatic RCC

1.14.1

For people with oligometastatic cancer who do not have symptoms, consider regular imaging using CT (or MRI, if CT is unsuitable) to monitor the disease before starting treatment with SACT.

1.14.2

For people with widespread metastases, offer any non-pharmacological interventions after, not before, starting treatment with SACT unless the person either:

  • has persistent symptoms that could be controlled by kidney surgery (see recommendation 1.14.4) or

  • urgently needs treatment of symptoms related to metastases (for example, in the brain, bone or spinal cord).

Treating the primary renal lesion in people with metastatic RCC

See also the section on information for healthcare professionals to discuss with people before and after kidney surgery, and NICE's guideline on perioperative care in adults for considerations around perioperative care and enhanced recovery programmes.

1.14.3

Consider cytoreductive nephrectomy (CN) before SACT for oncological control when:

  • immediate SACT is not indicated (for example, because of oligometastatic disease) and

  • surgery is suitable based on the renal lesion's and person's clinical characteristics.

1.14.4

Consider CN (before or after starting treatment with SACT) to manage persistent symptoms that could be controlled by surgery (for example, bleeding or pain).

1.14.5

Consider CN after starting treatment with SACT if:

  • the disease has had a durable partial response or better to SACT in the metastatic sites and

  • most of the disease that is left after SACT is in the primary site and

  • surgery is suitable based on the renal lesion's and person's clinical characteristics.

1.14.6

Discuss with the person why CN is or is not an option for them at this time and explain that in some cases this could change in the future.

Treating metastases

1.14.7

Consider non-pharmacological interventions to treat metastases, such as external beam radiotherapy (including stereotactic ablative radiotherapy [SABR]), metastasectomy or thermal ablation.

See the sections on radiotherapy and invasive interventions in NICE's guideline on spinal metastases and metastatic spinal cord compression, and the section on management of confirmed brain metastases in NICE's guideline brain tumours (primary) and brain metastases in over 16s.

See also the NHS England commissioning criteria for SABR for patients with metachronous extracranial oligometastatic cancer.

See also recommendation 1.12.2 in the section on referring people with advanced RCC, on using a specialist multidisciplinary team when additional input on treating metastases is needed.

1.14.8

Consider metastasectomy after SACT has been started when:

  • no new metastatic lesions have occurred for at least 6 months and

  • treatment could result in the person having no visible evidence of disease on imaging.

    See NICE's guideline on perioperative care in adults for considerations around perioperative care and enhanced recovery programmes.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on non-pharmacological management of metastatic RCC.

Full details of the evidence and the committee's discussion are in evidence review H: management of advanced renal cell carcinoma using non-pharmacological interventions.

1.15 SACT for advanced RCC

See the section on risk prediction tools for people with metastatic RCC to support SACT decision making, and recommendation 1.1.8 in the section on information for healthcare professionals to support people with suspected or confirmed RCC.

See also NICE's visual summaries on SACT for advanced RCC:

First-line treatment

Subsequent treatment

1.15.4

For medicines recommended as options for previously treated advanced RCC, irrespective of IMDC risk, in some people, see NICE's technology appraisal guidance on:

Neurotrophic tyrosine receptor kinase (NTRK) fusion-positive solid tumours

1.16 Palliative and end of life care for people with advanced RCC

See also the section on information for healthcare professionals to support people with suspected or confirmed RCC.

For a short explanation of why the committee made these recommendations and how they might affect practice, see the rationale and impact section on palliative and end of life care for people with advanced RCC.

Full details of the evidence and the committee's discussion are in evidence review D: information needs.