Assessing Your Risk and Adjuvant Therapy

After your surgery, the focus shifts to a critical question: “What is the risk that the cancer might come back?” To answer this, your medical team uses specialized tools to categorize your risk and decide if you need adjuvant therapy—preventative treatment given after surgery to kill any microscopic cancer cells that might remain ^[1][2].

Calculating Your Risk: The SSIGN Score

One of the most trusted tools for predicting the future behavior of ccRCC is the SSIGN score. It stands for:

• Stage (The pathologic ‘pT’ stage) ^[3]
• Size (The physical measurement of the tumor) ^[3]
• Grade (The WHO/ISUP nuclear grade, 1–4) ^[3]
• Necrosis (Whether the tumor shows signs of cell death) ^[3]

Each of these factors is assigned points. For example, a larger tumor or a higher grade adds more points to your total ^[3]. A low score means you have a very high chance of being cured by surgery alone, while a higher score suggests a greater need for close monitoring or preventative treatment ^[4][5].

The Breakthrough in Adjuvant Therapy

For many years, there were no proven drug treatments to help prevent ccRCC from returning after surgery. This changed with a major clinical trial called KEYNOTE-564 ^[1].

This trial showed that an immunotherapy drug called pembrolizumab (brand name Keytruda) significantly reduced the risk of the cancer coming back ^[1]. Most importantly, it was the first treatment to show that patients actually lived longer when they received the drug after surgery compared to those who only had surgery ^[1][6].

Who Qualifies for Preventative Treatment?

Not everyone needs adjuvant therapy. It is specifically reserved for patients at “increased risk of recurrence” ^[1][2]. This generally includes:

• Intermediate-High Risk: Tumors that are larger (pT2 with a high grade) or have grown into the fat or veins around the kidney (pT3) ^[7][8].
• High Risk: Tumors that have reached the lymph nodes or are even larger and more aggressive ^[7][8].
• M1 NED: Patients who had a small amount of cancer spread to another organ, but it was successfully and completely removed by surgery, leaving them with “no evidence of disease” (NED) ^[7][9].

If you are in a higher-risk category, adjuvant therapy is a highly recommended option, but choosing routine post-operative monitoring (observation without drug treatment) remains a completely valid choice to discuss with your doctor.

What to Expect During Adjuvant Treatment

If you and your doctor decide on adjuvant pembrolizumab, the treatment typically lasts for one year ^[1][10]. You will receive an infusion into a vein every three or six weeks ^[1].

While many patients tolerate immunotherapy well, it can cause the immune system to attack healthy parts of the body, leading to side effects like fatigue, skin rashes, or inflammation of organs ^[1]. However, your care team will monitor your bloodwork and symptoms closely to catch and manage these side effects early ^[7]. If you are low-risk, the standard of care remains routine post-operative monitoring—regular scans (CTs or MRIs) to catch any potential return early, without the need for drug treatment ^[11][12].