Questions to Ask About Kidney Cancer Treatment

For kidney cancer that can be removed, this is the decision with the longest shadow. It affects your kidney function for the rest of your life.

There are two operations.

Partial nephrectomy removes the tumor and spares the rest of the kidney. NCI states that in appropriately selected patients, its cancer outcomes are comparable to those of radical nephrectomy. It preserves more kidney function, and some studies link it to lower mortality.

Radical nephrectomy removes the whole kidney. A radical resection also takes the adrenal gland and the fat around the kidney. It takes Gerota's fascia too, the sheet of tissue enclosing them. Regional lymph nodes may or may not come out. NCI notes one clear case for this operation. It is preferred when the tumor extends into the inferior vena cava, the large vein returning blood to the heart.

Worth asking:

• Am I a candidate for a partial nephrectomy, and if not, what rules it out?
• What is my kidney function now, and what would it likely be after each operation?
• Will lymph nodes be removed, and how will that change what we learn?

Not everyone can have an operation. NCI lists several alternatives that can still be curative in selected cases:

• Cryoablation, which freezes the tumor.
• Thermal ablation, which heats it.
• Stereotactic ablative body radiation therapy, also called SABR or SBRT, which delivers focused radiation in a few high-dose sessions.

Ask which of these your center performs, how many they do, and how the tumor would be watched afterward.

This is the most nuanced part of kidney cancer care right now, and the honest version is more useful than a simple yes.

What the trial showed. KEYNOTE-564 enrolled 994 people with clear cell kidney cancer at high risk of return after removal. Four groups qualified. Stage II disease with nuclear grade 4 or sarcomatoid features. Stage III or higher. Regional lymph node spread. And metastatic disease with nothing left after surgery. Half received pembrolizumab by vein on a repeating schedule for about a year, at the fixed amount the protocol set. Half received placebo.

At a median follow-up of 24 months, the 2-year disease-free survival rate was 77.3% with pembrolizumab and 68.1% with placebo. At 30 months it was 75.2% versus 65.5%.

Longer follow-up changed the picture. The trial's third planned overall-survival analysis, published in the New England Journal of Medicine in 2024 at a median 57.2 months, reported a significant survival advantage: hazard ratio for death 0.62 (95% CI 0.44 to 0.87), with estimated 4-year survival of 91.2% on pembrolizumab against 86.0% on placebo. Serious side effects of any cause were still more common on the drug, 20.7% against 11.5%.

What it cost. Grade 3 or higher side effects occurred in 32% of the pembrolizumab group, and 20% had serious ones. The most common high-grade effects were diarrhea and raised liver enzymes, at 2% each. The most common serious effects were adrenal insufficiency, colitis, and diabetic ketoacidosis, at 1% each. Some of those are permanent hormone problems.

What NCI says about the evidence. This is the part patients rarely hear. NCI's clinical summary records that questions have been raised about the trial. Dropout in the early follow-up period was uneven, leaving gaps in recurrence data for the control group. Only 36% of the 166 control patients received immunotherapy when their cancer came back, even though immunotherapy clearly helps in metastatic disease. Two other adjuvant trials, one with atezolizumab and one with nivolumab plus ipilimumab, found no significant difference.

NCI goes further and writes that the FDA approval in this setting, along with NCCN and ESMO guidelines, may have been premature, and that more mature results were needed. That summary was last revised in May 2025 and still describes overall survival as awaiting longer follow-up; it has not yet caught up with the 2024 survival analysis above. Ask your oncologist which reading they are working from, and check the date on any figure either of you quotes.

Worth asking:

• Do I meet the KEYNOTE-564 eligibility criteria, or am I outside them?
• What is my personal risk of recurrence without adjuvant treatment?
• What survival benefit do you expect in someone with my risk profile, and from which analysis and date?
• Which side effects would be permanent if they happened?

Many kidney cancers turn up by accident. A scan ordered for back pain or an unrelated complaint shows a mass, and the conversation starts from there.

That matters for two reasons. Small tumors found this way may behave slowly, and some are not cancer at all. And a finding that arrived without warning tends to feel more urgent than the biology requires.

Ask what the imaging shows about size and about whether the tumor has grown into nearby veins or fat. Ask whether a biopsy would change anything before surgery is scheduled.

Whether or not you take adjuvant treatment, you will be watched. Ask for the schedule in writing, and ask what specifically is being watched for.

Useful specifics to pin down:

• Which scans, how often, and for how many years.
• Whether kidney function blood tests are part of the schedule, and who reviews them.
• What symptom would justify calling before the next appointment rather than waiting.

Two features of the pathology report drive later decisions. Ask that they be read to you.

Cell type. Clear cell renal cell carcinoma behaves differently from papillary, chromophobe, and rarer types. Most trial evidence, including KEYNOTE-564, was built in clear cell disease.

Sarcomatoid features and nuclear grade. These change risk category and can change eligibility for treatment.

If a genetic syndrome is suspected, ask about it directly. NCI notes that when tumors affect both kidneys, either at the same time or later on, a partial nephrectomy on both sides, or a partial on one side and a radical on the other, may be preferred to removing both kidneys.

Bring one page. Write down the operation being proposed, the alternative you want considered, and the two side effects you most want to avoid.

Ask which decision has a real deadline and which does not. Kidney tumors are often found by accident on a scan done for something else, and that can make everything feel urgent when parts of it are not.

If a clinical trial is mentioned, ask whether enrolling later is still possible after standard treatment starts. Clinical trial versus standard treatment explains how that choice works. For the disease itself, see kidney cancer, and for the full range of options, cancer treatment overview.

If you take adjuvant pembrolizumab, the side effects listed above are not just inconvenient. Adrenal insufficiency and diabetic ketoacidosis can both become life-threatening quickly, so know the signs before you start.

• Call 911 or go to an emergency department if you feel faint, weak and sick with dizziness on standing, or you have deep rapid breathing, breath that smells fruity, and heavy thirst with frequent urination. Get emergency care too for severe belly pain with a hard, tender abdomen, black or bloody diarrhea, chest pain, or sudden breathlessness.
• Call your cancer team at once, at any hour, if your temperature reaches 100.4 °F (38 °C) or higher while your blood counts are low from treatment; if nobody picks up quickly, go to an emergency department and tell them you are on cancer treatment. The CDC treats fever during cancer drug treatment as a medical emergency.
• Call your care team the same day if you have several more loose stools a day than usual, new yellowing of the eyes or skin, a new cough or breathlessness on mild effort, or you are passing much less urine than normal.
• Call your care team within a day or two if you notice a new rash, unusual tiredness, headaches that keep returning, or a change in appetite or weight that you cannot explain.

• National Cancer Institute, Renal Cell Cancer Treatment PDQ, health professional version, updated May 13, 2025; accessed August 6, 2026
• Centers for Disease Control and Prevention, Fever during cancer treatment; accessed August 13, 2026