Immunotherapy for advanced kidney cancer — how checkpoint inhibitors work, and who they are for

Immunotherapy does not attack the cancer directly. It works on your own immune system. The T cells that patrol for abnormal cells carry built-in brakes, called checkpoints, whose job is to stop them turning on healthy tissue. Kidney cancer can press those brakes, so the immune response switches off before it does the tumour any damage. A checkpoint inhibitor blocks that off signal, and the T cells that were already there are able to go back to work. Two checkpoints are used in kidney cancer: one acts where the T cell meets the tumour, the other earlier, where new T cells are first switched on. Because the effect is on your immune system rather than on the tumour, both the benefit and the side effects behave differently from chemotherapy.

It is used mainly for kidney cancer that has spread beyond the kidney or has come back after surgery, and it is considered after surgery in selected cases where the risk of the cancer returning is higher. It is not the usual answer for a small tumour still confined to the kidney, where surgery, ablation or careful monitoring are discussed first. Before it is offered, your team weighs how fit you are for treatment, your kidney, liver and thyroid results, and whether you have an autoimmune condition, a transplanted organ or are taking long-term immune-suppressing medicine, because any of those changes the balance. At CION that decision is made at a tumour board and given to you in writing, not settled by one doctor alone.

It is given as a drip into a vein in a day-care unit, on a repeating cycle with a gap of a few weeks between doses. Each visit takes a few hours including the checks beforehand, and you go home the same day. There is no hair loss and no hospital admission for the treatment itself. Before every cycle your blood counts, kidney, liver and thyroid results are checked and you are asked how the last cycle went, because immune side effects are found by asking as much as by testing. How long treatment continues depends on whether it is working, how well you are tolerating it, and the plan agreed at the start, which your oncologist should set out in writing before the first dose.

By repeat scans and by how you actually feel, read together. The first assessment scan is usually done after several cycles rather than after the first, because immune-based treatment can take longer to show its effect than chemotherapy does. Occasionally an early scan looks a little worse before it improves, as immune cells move into the tumour, which is one reason a single scan is not acted on in isolation. Symptoms count too: pain settling, appetite returning, energy improving. If the disease is clearly progressing on imaging and you are also feeling worse, the plan is changed rather than continued. It is fair to ask when the first assessment scan is due and what would count as a reason to switch.

No. Chemotherapy acts on cells that divide quickly, which is why it affects hair, the lining of the gut and the bone marrow. Immunotherapy does not act on the cancer at all. It takes a brake off your immune system and lets your own T cells do the work. That difference shows up in three ways. The side effects are different, being inflammation in an organ such as the thyroid, bowel, skin, liver or lungs rather than low blood counts and hair loss. The timing is different, because benefit can take longer to appear and can carry on after treatment stops. And it matters here in particular, because the commonest kidney cancer responds poorly to traditional chemotherapy, which is why chemotherapy is not the mainstay in this disease.

This page stays with the class and the mechanism rather than naming molecules, because which one is chosen depends on your risk group, the tumour type on pathology, what you have already had and your other medical conditions. In practice a checkpoint inhibitor is rarely used on its own as the first treatment for advanced kidney cancer. It is usually paired, either with a second immune drug that works at a different checkpoint, or with a targeted drug that blocks the blood supply the tumour builds for itself. The named regimens, how they are chosen along NCCN lines and what each costs are set out on our kidney cancer treatment page. Bring your reports and ask for the choice to be explained before anything starts.