Kidney cancer: symptoms, treatment and survival

Kidney cancer is a malignant tumour of the kidney. The most common type is renal cell carcinoma (RCC), accounting for approximately 85% of cases, with clear cell RCC being the most frequent subtype. Around 13,000 people are diagnosed in the UK each year and approximately 5,000 die annually. Kidney cancer is more common in men than women and most frequently affects people aged 60–75.

Kidney cancer is frequently asymptomatic in its early stages — many cases are discovered incidentally. When symptoms do occur, they include: haematuria (blood in the urine — the most common symptom, affecting approximately 60% of patients at presentation); persistent back or loin pain; a palpable mass in the flank or abdomen; unexplained weight loss; fatigue; night sweats; fever; and high blood pressure. Any episode of painless blood in the urine requires urgent investigation.

The exact cause of most kidney cancers is unknown, but established risk factors include: smoking (doubles the risk); obesity; hypertension; a family history of kidney cancer; and inherited conditions — notably von Hippel-Lindau (VHL) disease, which causes a significantly elevated risk of clear cell RCC. VHL gene inactivation — whether inherited or acquired — is the most common molecular event in clear cell RCC. Long-term analgesic use, chronic kidney disease and male sex are also risk factors.

Haematuria is the presence of blood in the urine. It can be visible (macroscopic haematuria — the urine appears pink, red or brown) or detectable only on dipstick testing (microscopic haematuria). Painless macroscopic haematuria in an adult is a red flag symptom requiring urgent investigation to exclude urinary tract malignancy — including kidney cancer, urothelial (bladder/ureter) cancer and prostate cancer. Any adult with a single episode of painless visible haematuria should be referred via the Two Week Wait cancer pathway.

Investigation begins with urine dipstick and microscopy, blood tests (FBC, renal function, LFTs, calcium) and an ultrasound of the kidneys. If a renal mass is detected, CT of the chest, abdomen and pelvis with intravenous contrast provides detailed characterisation and staging. MRI is used for equivocal masses or to assess venous involvement. Image-guided percutaneous biopsy is increasingly used to guide management decisions for smaller masses. Cystoscopy is performed if urothelial malignancy is also suspected.

Kidney cancer is staged I–IV. Stage I: tumour 7 cm or less, confined to kidney. Stage II: tumour over 7 cm, confined to kidney. Stage III: tumour extends into major veins (renal vein or inferior vena cava) or perinephric fat, or involves regional lymph nodes. Stage IV: tumour extends beyond Gerota's fascia (surrounding tissue) or involves the adrenal gland, or distant metastasis (most commonly lung, bone, liver, brain). Five-year survival: Stage I ~90%; Stage II ~75%; Stage III ~55%; Stage IV ~12%.

Localised kidney cancer: surgery (partial nephrectomy preferred for smaller tumours; radical nephrectomy for larger/complex tumours) — laparoscopic or robotic approach where possible. Ablation (radiofrequency ablation, cryoablation) for small tumours in patients unfit for surgery. Active surveillance for small, slow-growing tumours. Metastatic/advanced kidney cancer: immunotherapy combinations (nivolumab + ipilimumab; pembrolizumab + axitinib; nivolumab + cabozantinib — NICE approved); targeted therapy (sunitinib, pazopanib, cabozantinib).

Partial nephrectomy (nephron-sparing surgery) is a surgical procedure in which only the tumour-bearing portion of the kidney is removed, preserving the remaining functional kidney tissue. It is the preferred approach for tumours amenable to it — particularly those under 7 cm in a patient with a normal contralateral kidney — as it preserves renal function and reduces the long-term risk of chronic kidney disease and cardiovascular events. Laparoscopic (keyhole) or robotic partial nephrectomy is standard at specialist centres, with shorter recovery than open surgery.

Immunotherapy for metastatic kidney cancer uses drugs that activate the immune system to recognise and attack cancer cells. The most commonly used immunotherapy agents are checkpoint inhibitors targeting PD-1 (nivolumab, pembrolizumab) and CTLA-4 (ipilimumab). NICE-approved first-line combinations include: nivolumab + ipilimumab (for intermediate and poor-risk metastatic RCC); pembrolizumab + axitinib and nivolumab + cabozantinib (for all risk groups). These combinations have transformed the prognosis of advanced kidney cancer, with significant proportions of patients achieving durable responses lasting years.

Five-year survival rates in England: Stage I — approximately 90%; Stage II — approximately 75%; Stage III — approximately 55%; Stage IV — approximately 12%. Overall five-year survival for all stages is approximately 60%. Survival outcomes for metastatic kidney cancer have improved substantially over the past decade with the advent of immunotherapy-based combinations, with a significant proportion of patients achieving long-term disease control.

The most important preventive measures are: stopping smoking (smoking doubles the risk of kidney cancer — quitting reduces it substantially); maintaining a healthy weight (obesity is strongly associated with kidney cancer risk, particularly in women); managing hypertension; and maintaining a healthy lifestyle. Inherited conditions causing elevated kidney cancer risk (VHL, Birt-Hogg-Dubé, hereditary papillary RCC) should be identified through family history assessment and genetic testing, allowing enhanced surveillance of at-risk individuals.

Most kidney cancers are sporadic, but approximately 3–5% are hereditary. Von Hippel-Lindau (VHL) disease (caused by germline VHL mutations) is the most common hereditary kidney cancer syndrome, causing multiple bilateral clear cell RCCs along with haemangioblastomas and phaeochromocytomas. Birt-Hogg-Dubé syndrome causes chromophobe RCC and oncocytomas. Hereditary papillary RCC is associated with MET mutations. Hereditary leiomyomatosis and RCC (HLRCC) is caused by FH gene mutations. Referral to Clinical Genetics is appropriate for patients with young-onset kidney cancer or a strong family history.

Von Hippel-Lindau (VHL) disease is a rare inherited condition caused by germline mutations in the VHL tumour suppressor gene. It is characterised by the development of multiple tumours including clear cell renal cell carcinomas (often bilateral and multifocal), haemangioblastomas of the brain, spinal cord and retina, phaeochromocytomas and pancreatic neuroendocrine tumours. Kidney cancer in VHL disease develops in approximately 70% of patients, often in their 40s. Management involves enhanced surveillance from adolescence and nephron-sparing surgery or ablation for renal tumours when they reach intervention threshold (3 cm).

Yes. Kidney cancer most commonly spreads to the lungs (the most frequent site of distant metastasis), bone, liver, brain and adrenal glands. Metastasis may be present at diagnosis (synchronous) or develop after initial treatment (metachronous). Kidney cancer can also spread directly into the renal vein and inferior vena cava (venous tumour thrombus), which has surgical implications. Distant metastasis at diagnosis occurs in approximately 20–30% of patients at presentation. The IMDC (International Metastatic RCC Database Consortium) score predicts prognosis in metastatic RCC.

Targeted therapies for kidney cancer include VEGFR tyrosine kinase inhibitors (TKIs) — sunitinib, pazopanib, axitinib, cabozantinib and lenvatinib — which block the VEGF pathway that clear cell RCC depends on for its blood supply. These drugs prolong progression-free survival in metastatic clear cell RCC. mTOR inhibitors (temsirolimus, everolimus) were formerly widely used but are now less central. These targeted agents are given as oral tablets and are associated with side effects including hypertension, fatigue, diarrhoea, hand-foot syndrome and hypothyroidism.

A kidney cyst is a fluid-filled sac in the kidney. Simple cysts are extremely common — affecting over 50% of people over 50 — and are almost always benign. They are classified using the Bosniak classification system (I–IV) based on CT characteristics. Bosniak I and II cysts are benign and require no intervention; Bosniak III and IV cysts (complex, with thickened walls, calcification or solid components) have increasing malignant potential and require urological assessment and possible surgery. Solid renal masses are more likely to be renal cell carcinoma and require urgent investigation.

Yes. The human body functions perfectly well with one kidney — the remaining kidney compensates by increasing its filtration capacity. Most people who have had a kidney removed (nephrectomy) for cancer live normal lives with normal or near-normal renal function. Long-term, a single kidney does increase the risk of developing chronic kidney disease and hypertension, particularly if the remaining kidney is also affected by disease. Blood pressure monitoring, avoiding nephrotoxic medications, maintaining hydration and regular kidney function checks are recommended.

Flank or loin pain is one of the classic symptoms of kidney cancer, though it is not present in all cases — and when it does occur, it is typically described as a dull, persistent ache in the side or lower back rather than acute pain. Back pain is a very common symptom with many causes; it is not a sensitive or specific indicator of kidney cancer alone. Painless haematuria (blood in the urine) is the most important warning symptom. Pain in the context of haematuria, an unexplained mass or significant weight loss requires urgent investigation.

In low-income countries, kidney cancer is often diagnosed at a late stage because abdominal imaging is not widely available and the incidental detection that drives earlier diagnosis in high-income countries does not occur. Targeted therapies and immunotherapy combinations — transformative in high-income settings — are unaffordable for the vast majority of patients in low-income countries. Surgical expertise for nephrectomy may be limited outside major urban centres. World Aid Network funds cancer treatment through locally-licensed oncologists, helping to provide access to care for poor patients.