Nice article, Dr. West,

My question: If primary tumor/mets remain after the standard 4-6 cycles – at what point does the patient move to second line chemo? In our particular case – Mum’s Doc has decided on continuation of first line Carbo/Etoposide without our “begging for mercy”. It could be assumed that this would be maintenance therapy, but wouldn’t advancing to second-line be more appropriate?

Also – as a completely off topic question – I’d like to know the physiology of what happens to the “space” that once occupied a lung tumor. Does it fill will fluid? Can it cause pain even if tumor is dissolved? What takes the place of the tumor – as it obviously has eaten away at the lung tissue. Why would someone have continued chest discomfort even though chemo appears to be working and initial symptoms have long ago resolved?

Thanks again, Dr. West,
Leanne

I think my wife was ‘begging for mercy’ even before the 2 cycle was complete. We were begging for Tarceva but her Onc. just couldn’t bring himself to believe in it.
When she finally and painfully got through the 2nd cycle after many complications and delays her Onc finnaly gave in to Tarceva 150.
Within a month on Tarceva the lung tumor had disolved. This may sound strange but her Onc was more than happily surprised. I wished her Onc could have believed in it sooner.
I would like to add to the off topic question. This was a timely Reply by Leanne.
The death of my wife’s lung tumor did produce an air cavity. Her 3 month CT scan revealed that the cavity had filled with fluid. We haven’t had the office visit yet but I called in for a report and her Onc read the report and called back and called her condition Stable.
Does that sound right?
I’ll get the details next week. She has been experiencing more pain in her back on the side of the affected lung.
Could that be from the fluid?
Thanks again – Chanwit

Anecdotally, I’m a 28 year old stage iv nsclc survivor. I just finished 6 cycles, and my tumors (including bone mets) continued to respond after the fourth treatment, half of them “resolving.”

I assume that I would get more response with more than 6 treatments, but chemotherapy is one of the most disgusting things in the world and just thinking about it now is making me nauseated.

This is an incredible site for someone like me by the way. Keep it up Doc.

Lots to comment on here. Lung lesions can cavitate, which means have the cancer cells die in the center of the tumor but the outside rim remain intact. The current response criteria call this stable, because the tumor is still the same size. When cancer dies on the outside, so that the tumor actually shrinks, that material gets resorbed by the body, and things like lung nearby that get pressed away by a growing tumor can sometimes re-expand. Sometimes there’s an inflammatory/scarring response, but that’s more typical after radiation than chemo alone. Sometimes just the changes as lung tissue compresses or re-expands can cause discomfort. I’m not sure I can well explain pain in the area of a shriking tumor otherwise.

Spicysashimi, that’s great that you had a response that continued to work for so long. I have a few patients who have broken the rules and had prolonged responses, but it’s under 5% of the people who I treat who I’d be tempted to recommend continue beyond 6 cycles of the same chemo. And to do that, patients also need to be tolerating that treatment pretty darn well. Your situation illustrates the need to balance efficacy against tolerability/quality of life.

As for Leanne’s question of when to switch to second line, I generally recommend that patients not jump right into second line therapy in the absence of progression. I would consider the question of continuing first-line therapy vs. stopping treatment as the first question. As I showed with things like the Erbitux trial and Avastin, maintenance therapy trials kind of roll right on without end after a certain number of chemo cycles, and that’s fine, but I would really wonder whether patients, at least the ones on conventional chemo, which tends to be harder to tolerate indefinitely, might do better to have a real break from treatment for several months before starting second-line treatment. Patient energy and bone marrow reserve are finite resources, and I generally recommend that they take some time off (if possible) to help do as well as possible on second-line treatment. That’s just my preference, without any proof of a best approach, and some patients are very wary about being off treatment. It’s something I end up individualizing with my patients.

-Dr. West

This discussion is very timely. I’ve just begun my 6th cycle of Taxol/Carbo/Avastin for NSCLC Stage IIIB/IV adenocarcinoma (details in recce101 profile on lchelp.org). CT scan after cycle 3 showed some reduction in size of existing lesions and no new lesions. Up to this point blood counts have been good and side effects tolerable, though I’ve been eagerly awaiting the planned change to Avastin only after cycle 6. But two days ago, during the pre-infusion exam, my onc planted the seed that “we might consider” extending the Taxol/Carbo/Avastin regimen out to 7 or 8 cycles if the upcoming CT scan on 1/30 shows continued improvement. I joked with the chemo nurse that I should exaggerate my next side effects report to hasten the switch to Avastin only, but seriously, what factors should I consider in deciding whether to welcome an extension of the three-drug program?

As I mentioned above, I have had only a few patients in whom I’ve recommended more than 6 cycles of first-line chemo in the last few years. I have been inclined to consider or recommend it for the very uncommon situation of additional tumor shrinkage ongoing at a scan after the sixth cycle, compared to the preceding one after 3 or 4 cycles (I generally obtain CT scans after every two cycles). If there has been additional tumor shrinkage (not just stable disease) AND the patient is tolerating it well without cumulative toxicities (like problems with neuropathy on paclitaxel, or increasing problems with low blood counts) AND the patient is game, that’s the situation in which I’d be most inclined to follow that strategy. However, it’s not like 6 cycles of the three drug combination followed by maintenance avastin is taking it easy. That’s a pretty respectable and aggressive treatment plan in its own right.

But the basic answer is, it depends a lot on what the CT shows after 6 cycles, further shrinkage vs. anything else.

-Dr. West

My dad was on carbo/taxoter/avastin for about a month and a half. After his first CT scan, the doctor saw that things remained stable with verrrry slight shrinkage in one tumor. As a result, he stopped chemo and has my dad on Tarceva (150 mg) for 30 days and will do another scan to see if there will be significant shrinkage. If not, he will put him back on chemo. Was chemo stopped too early in his case? Will flip-flopping from one regimen to another have a bad effect?

Thanks
Rochelle Valencia

Rochelle,

We never had so many potentially useful tools available, and while most chemo regimens have pretty stable patterns of response or progression, targeted therapies like tarceva are more of a wild card. The rules are blurrier with so many potential useful agents, and I and many oncologists will often discuss the possibilities and modify plans. I can certainly understand shifting as a “window of opportunity” to a very different approach, to see if your father might get a better benefit with a very different drug like tarceva.

I would never want to imply that these are hard rules. They’re always called guidelines, not the laws of oncology, that can be modified depending on the patient and particular situation. And there is still room for a good rationale and carefully discussion with a patient about when to deviate from the guidelines. They also don’t tend to change more than every few years, and new data emerge all the time.

-Dr. West