Radiotherapy
Radiotherapy is not often used for the treatment of advanced renal cancer because renal cell carcinomas are not as sensitive to radiation as other types of cancer. It is sometimes used to help control the symptoms of advanced renal cancer, for example to help relieve bone pain or to treat metastatic disease in the brain. Radiotherapy can be used to shrink tumours to reduce pressure on nerves and other organs thereby helping to control neuropathic pain and discomfort caused by compression of internal organs.
Radiotherapy can be very successful at controlling symptoms and slowing down the growth of brain metastases. It can be given in a number of different ways and is usually given in combination with steroids. How it is given depends mostly on the size and number of areas of cancer spread in the brain. If there is only one area affected, it may be treated with stereotactic radiotherapy using high doses of radiation directed at the metastasis using a head frame to ensure precision. Only a single treatment is required. Stereotactic radiotherapy is sometimes called radiosurgery or gamma knife treatment.
If stereotactic radiotherapy is not available, lower dose radiation is usually given in 10 separate fractions over 2 weeks. If there are widespread areas of the brain affected or if there is the possibility of the spread of cancer cells throughout the brain, which are too small to detect on a scan, whole brain radiotherapy is employed. This is usually given in 5 fractions over a week.
Analgesia
Analgesia obviously has a large part to play in the palliation of pain secondary to renal cancer. Pain might be experienced as a result of the renal cancer itself or as a side effect to renal cancer treatments. Common analgesics used for pain management in renal cancer patients are tramadol, co-codamol, diclofenac sodium and paracetamol. Caution should be exercised in prescribing non-steroidal anti-inflammatories (NSAIDs) to patients with compromised renal function. Analgesia may be supplemented or in some cases replaced by non-medical interventions, such as meditation and relaxation therapies.
Nausea
Nausea may have a number of causes, including systemic treatment (immunotherapy, targeted therapy), radiation treatment, tumour growth, or anxiety about the disease. A variety of strategies aimed at reducing nausea may be attempted, ranging from eating smaller meals to drinking smaller amounts of fluids more frequently, drinking salty fluids, and engaging in relaxation exercises. If these techniques are not effective, oral anti-emetics can significantly reduce symptoms of nausea. Various anti-emetics or combinations of anti-emetics can be tried until a successful outcome is achieved.
Fatigue
Fatigue is one of the most distressing side effects of cancer, and can significantly impact the life of the patient. Fatigue may be caused by many factors, including depression, insomnia, anaemia, the effects of cancer treatment, and metabolic disturbances caused by the cancer.
To combat fatigue, patients are advised to pace their activities and prioritize where they expend their energy. Organising home and work environments in a way to help accommodate lower energy levels can help. Patients should be advised to limit physical activity before, during and after renal cancer treatment. Regular, gentle exercise and a healthy diet will help to reduce fatigue, and treatment for anaemia may also help. Patients should make sure they do relaxing activities; reading, listening to music, watching TV, and a nap during the day can help a great deal to combat fatigue.
Constipation
It is not unusual for cancer patients to become constipated. Contributing factors are pain medications, cancer treatment, lack of exercise, and poor nutrition. In many cases, nutritional adjustments, such as a high fibre diet and increased intake of water can help to relieve constipation. If this is not successful, consider the administration of laxatives.
Nutrition
At all stages during their renal cancer journey, a healthy, well-balanced diet will help the patient maintain strength and alleviate fatigue, prevent infection, promote regeneration of normal body tissues and prevent body tissues from breaking down. Good nutrition and maintaining calories is especially important when patients are undergoing intense treatments, such as surgery, radiotherapy and systemic treatments. Foods rich in vitamins A and C, and high fibre foods to combat constipation are beneficial. Advice from a nutritionist may need to be sought.
Psychological, Social and Spiritual Support
It is common for people with renal cancer to be affected by psychological distress; this is an understandable response to a traumatic and potentially life-threatening experience. Some patients will be able to draw on their own inner resources to help them cope, while others gain emotional support from family and friends. Some patients, however, are likely to benefit from additional professional intervention because of the level and nature of their distress.
Psychological symptoms are often not identified in practice and patients should undergo systematic psychological assessment at key points during the progression of their disease.
Depression is common in patients suffering from late-stage renal cancer. Professional psychological intervention may help some patients and non-medical interventions, such as meditation and relaxation therapies may help. Alternatively, current low-dose antidepressants are safe, well tolerated and effective as treatment for clinical depression. However, care must be employed when prescribing antidepressants during the end stages of a person’s life, because drugs can interfere with the natural grieving process.
The social impact of cancer is considerable and can reach beyond the patient and immediate family. Patients may need support from health and social care services to:
- Help preserve social networks;
- Provide support with personal care, cleaning and shopping;
- Provide care for vulnerable family members;
- Provide advice on employment issues;
- Assist in securing financial benefits.
Communication between local health and social care services and the voluntary sector is essential to ensure that the needs of renal cancer patients and their carers are met in a timely fashion.
The diagnosis of a life-threatening disease can raise unsettling questions for some patients. They will seek to re-examine their beliefs, whether philosophical, religious or spiritual in nature. Patients and their families or carers should have access to staff who are sensitive to their spiritual needs and a suitably qualified and authorised spiritual care giver should be appointed to the multi-disciplinary team providing palliative care. Staff should also be aware of local community resources for spiritual care.