Active Surveillance

Active surveillance is observing a kidney tumour or multiple tumours through regular imaging. For some patients, no further intervention is needed, while for others, certain triggers can indicate that additional treatment is required.

Patients with tumours smaller than 2 cm are ideal candidates for active surveillance due to the low risk that the tumour will spread during observation. Patients with small kidney tumours up to 4 cm can be safely watched based on several factors.

Who may be a candidate for active surveillance?

The hospital urology doctor may discuss this approach if you:

• Have poor kidney function. Since any intervention on the kidney can cause further deterioration of kidney function, impaired kidneys may be a reason to recommend active surveillance to lessen the chance of requiring dialysis. Dialysis, while lifesaving, can have an impact on a person’s quality of life. The doctor/urology team will carry out blood tests that look at levels of creatinine or estimated glomerular filtration rate to assess kidney function.
• Live with hereditary forms of kidney cancer.
• If a person has a genetic condition such as Von Hippel-Lindau
  syndrome, Birt-Hogg-Dubé syndrome, or Tuberous sclerosis they are at an increased risk of developing multiple tumours on both kidneys. Sometimes active surveillance is used to wait to discover the true number and location of tumours before committing to surgery. The number of operations over a lifetime should be minimised to reduce scar tissue and other complications. It is also preferable to avoid recovering from surgery to then discover there were other tumours developing. These tumours are typically managed with active surveillance until they reach 3 cm or larger.
• Have drug-eluting heart stents and need to be on a blood thinner medication. Kidney surgery and other interventions can result in severe bleeding. A period of active surveillance until the person can come off the blood thinners may be helpful to avoid potentially serious complications.
• Are older and medically fragile. Kidney tumours have a low risk of spreading. Older adults and patients with other health problems should discuss if active surveillance is an option.
• Are experiencing or recovering from an active serious medical problem or condition. A period of active surveillance can monitor a kidney tumour until health improves.
• Do not wish to have surgery or treatment.

What does active surveillance involve?

The exact surveillance plan is tailored to the patient. The process may start with a complete staging evaluation (blood tests and imaging scans of the chest, abdomen and pelvis to rule out spreading cancer. A kidney biopsy may be required (needle inserted into kidney, through the skin to take a sample of the tumour for pathology characterisation)the tumour biopsies will hopefully be able to discover the type of tumour by looking at the cells under a microscope: this can provide information to predict how the tumour will behave. For patients with an indeterminate small kidney tumour for which treatment is being considered. Identifying the pathology of small renal masses decreases the risk of unnecessary treatment if the tumour sample confirms benign (non-cancer). The scans most carried out are a CT (computerised tomography) scan, MRI scan (Magnetic resonance Imaging) , ultrasound, and chest x-ray. Regular scans will be taken to actively monitor the tumour/ tumours. The doctors will discuss what is the most appropriate scan and will discuss the recommended timelines for imaging, this may be every three, six or 12 months
.

Can the kidney tumour spread while I am on active surveillance?

The answer to this is, unfortunately, yes. However, the risk is very low, all people and tumours are unique, and this risk should be discussed with your urologist.

When might a patient require treatment beyond active surveillance?

The most common trigger for intervention is tumour growth of 5 or more millimetres a year, which increases the chance of having a potentially aggressive cancer.

Active surveillance is not for everyone, and many people prefer to opt for surgery immediately. This will be a very personal decision and an important discussion to have with the urology specialist. Click here to access further information on Kidney Cancer surgery