General

Congratulations on your good news! I follow my patients with serial CT scans, gradually increasing the interval between scans the farther a patient is from his original diagnosis.  I do not usually repeat bone scans, PET scans or brain MRI unless a patient has symptoms or an abnormality shows up on CT scan.  For a tumor or metastatic deposit to show up on a PET scan, it generally has to be about 1 cm, a size which would easily be visible on a CT scan.  If I have a patient develop a new spot on a CT scan, I will often follow this up with full restaging, obtaining a PET and a brain MRI before deciding on treatment.   

Patients often wonder why we do not perform more scans or perform scans more frequently than we do.  One of the main reasons we perform scans is to make sure we do not miss a potentially curable second lung cancer or a recurrence confined to the chest.  Performing scans every 3-6 months in the first few years and annually after 5 years is generally more than enough to accomplish this.  Although an isolated brain or bone metastasis can occur, it is much more common that patients develop a recurrence that is visible on CT scan along with a recurrence in bone or brain.  I also find a lot of value in taking a good history at each follow-up visit.  Subtle clues like weight loss, change in energy or appetite, or neurologic symptoms can often point a doctor in the direction of a recurrence. 

Finally, there is no way to head off a metastasis by scanning more frequently. We currently have no evidence that scanning more frequently or with more types of tests improves a patient's prognosis.  If an asymptomatic metastasis has occurred, it is unlikely that finding it a few weeks will make a difference in a patient's long-term prognosis.  I think the way forward in lung cancer is to find ways of figuring which patients are likely to recur and where so that we can target our treatments appropriately but we not there yet.

-Dr. Pinder

Dr. Pinder,  Thank you for your explanation regarding scans. 

Can you comment on his anemia, and the iron infusion? 

He has been extremely fatigued since his chemo on 11/30 (Gemzar & Taxotere).  Wed thru Fri he was barely able to get off the sofa once or twice.  His last Hemoglobin was 8.4, and they ran an iron test.  They called to say he will get an iron infusion along w/ his Gemzar on Monday 12/7.  I am assuming the iron will help with the anemia, and I know anemia can cause fatigue, but this has been the worst he has felt.  He did fairly well with his first chemo, 3 cycles of Cisplatin and Taxol starting back in August). So we were a bit suprised when he was feeling so fatigued after this new drug combo.  Once he gets the iron should that help with the fatigue?  I know the new drugs can also affect his counts, so  I was unsure of how long he might have the extreme fatigue.

Also, he spiked a fever of 100.8 on Thur evening, the oncologist had him start a course of Cipro, though he had no other symptoms.  The fever went away overnight and then it spiked at 100.7 on Fri evening.  I read that Gemzar can cause fever, would this type of fever pattern be from the Gemzar? 

Thanks, Kim

   Gemcitabine and taxotere is a combination that can be tough on blood counts as well as symptoms, and it doesn't surprise me that you're seeing a lot of fatigue.  I wouldn't anticipate any quick reversal with an iron infusion.  This would be given in hopes of shortening the time for his bone marrow to make new red blood cells, and thereby improve his anemia, but it's not a fast process and will probably take many weeks and sometimes can extend out to months to have the hematocrit (percentage of the blood volume that is red blood cells) inch up.   

   At the same time, fatigue in the setting of chemo typically has many potential causes.  We often see patients without much anemia who are plenty fatigued after chemo.  It can definitely be related to the chemo more directly.

   In terms of fevers, you can definitely see that after gemcitabine and sometimes other chemo agents.  It's quite common for oncologists to start patients on a broad spectrum antibiotic as an outpatient if their blood counts aren't especially low but they have low grade fevers or just feel unwell.

-Dr. West

I can second Dr. West's comments - gemcitabine and Taxotere is a pretty tough regimen, especially in someone who has recently undergone cisplatin and Taxol.  The anemia could certainly be contributing to the fatigue. 

When patients are on chemotherapy, the body's ability to make new red blood cells is impaired so even if adequate iron is present, patients may still be anemic.  In this situation, sometimes a blood transfusion is the only way to improve a patient's anemia. 

-Dr. Pinder

One additional option that can be considered are ESA (erythropoiesis stimulating agents).  These are shots that can increase the red blood cell count.  When a person needs more red blood cells, the kidney sends a signal to the bone marrow to ask it to make more--this is called epogen.  The shots send a mimic of epogen, to drive to the marrow to make more.

These agents have become a tad controversial lately.  In my opinion, they have gotten a bad name because they were used too agressively and in the wrong patients.  In a patient who has never had a blood clot, and whose hemoglobin is <10 as a consequence of chemotherapy, their use can increase Hgb and decrease the need for blood transfusion.  The appropriateness of these agents for an individual patient must be made be their hematologist/oncologist who knows their full medical history.

  There's no question that they have a bad name now, and I also think there's little question that they were over-used previously.  However, I personally remain very reluctant to use ESAs because there is some relatively recent evidence that they are associated with lower survival in some cancer patients, for reasons that are still unclear.  Transfusions aren't something we relish, but they aren't inherently a dreaded outcome, in my opinion.  In fact, I recently read that there was no real evidence that our blood product requirements/rates of transfusions dropped significantly during the "heyday" of ESA use/overuse. 
 
   However, I don't mean to say that ESAs are always a bad choice -- not at all.  I just fall more on the side of reluctance when the survival benefit suggests a detrimental effect in cancer patients, even if it's mixed and imperfect data.

-Dr. West

Wed evening my husband spiked a fever of 102.5.  After speaking to the oncologist I took him to the ER, where they ultimately admitted him.  He got a course of Gemzar, as well as an iron infusion on Dec 7.  He was already on a course of Cipro from a fever (100. last Thursday.  His wbc was only 800, so they gave him two IV antibiotics, and fluids.  It was strange, b/c at the hostpial his fever was only 99.2.  I had done cold compresses in the car, but no fever meds.  Would an infection cause fever spikes, and then practially return to normal w/o medication?     

Also, does this mean he won't be able to continue on his current chemo course?   His next cycle isn't until Dec 21 (Gemzar and Taxotere)?   

It is 3 am EST and I have just gotten home from the hospital, I can't sleep, b/c I am so worried about him. 

Any input would be appreciated.   Thanks

Even fevers from infection can fluctuate so it is impossible to rule out an infection by the fever pattern and I would definitely still be concerned about infection in a patient with a fever of 102.5 and a low WBC count. 

While the blood counts typically recover in time for the next cycle of chemotherapy, when a patient has a very low WBC, especially in conjunction with a fever, I will usually modify the next cycle of chemotherapy.  These modifications can include the addition of a WBC growth factor like Neulasta or Neupogen and/or a dose reduction in the chemotherapy.

Dr. Pinder

Does a reduction in the chemotherapy make it less effective? 

He is getting the Gemzar / Taxotere week 1, Gemzar only week 2, and nothing week three.  Then cycling back to week one, for three cycles total.  We have no way to measure effectiveness, other then the absence of anything on the scans, because this is post surgical chemo being given due to 4 positive hilar nodes, and one positive node at station 5.  Plus he had a positive margin, and will be getting 6 weeks of radiation post chemo. 

I have heard of Neulasta, are there any major side affects or risks from this drug?

Thanks,  Kim

   Dose reductions are very common and are really a standard part of individualizing treatment for patients.  We start at what is really often close to the "maximum tolerated dose" for a majority of patients and then typically dial down as significantly low blood counts and/or other problematic side effects dictate.  Because the dose reduction still reflects the maximal dose that a patient can typically tolerate, we consider that the appropriate dose for them.  I'm not really aware of evidence to suggest that people who get dose reductions do worse than other people in this setting.

   Neulasta is a medication that helps boost the white blood cell count faster for patients who have experienced a very low white blood cell count or are at quite high risk to do so, depending on some patient characteristics and also the regimen being given (some are far more likely to drop blood cell counts a lot than others).   Because its effects are about equivalent to nine days of the daily white blood cell booster G-CSF (Neupogen), Neulasta is only indicated for people who have an interval of at least a couple of weeks between their chemo infusions.  Otherwise, people generally use daily G-CSF injections to achieve the same effect if it's felt necessary to help boost the white blood cell count faster.  The main side effect of both of these agents is bone pain in some people, and occasionally we'll also see fevers afterward. 

-Dr. West

The doctor gave my husband 2 units of blood, and that helped to raise his hemoglobin to over 8. They also gave him Neupogen to increase the wbcs.  As of Sunday morning his white count and neutrophils were normal.  Also during the course of his stay he was put on Zosyn and Vancomycin IVs.  They never did find any source of infection (blood cultures and urine cultures negative).  He came home from the hospital around 5 pm EST Sunday.  This evening we noticed a mild rash on his stomach, and inner thighs.  It was not very itchy, and there were no hives / swelling, just a little red and some splotchy redness on his upper inner thighs.  Could this be from one of the antibiotics, or the Neupogen?  He didn't have hives and was not having any difficulty breathing or anything like that.   I gave him some Benadryl, and put some Cortisone cream on him, and will watch it over night.   
Also, he had a fever again of 100.3, so he took two Tylenol.  If they ruled out infections, and he has been on antibiotics why would he still be spiking a fever?   His Gemzar treatment was Dec 7.  Could the fever be totally unrelated to any infection and just a delayed reaction to the chemo? 

Thanks

   That sounds like an allergy to a drug, and many antibiotics can do this -- zosyn would be a strong consideration, since it's in the penicillin family, and it's extremely common to have an allergy to penicillin and its cousins.  This in itself could cause a low grade fever, but there are many other possibilities, includng neupogen.  I would just caution that a temperature of 100.3 isn't really "spiking a fever".  A fever is multiple readings over 100.4F over a 24 hour period, or one reading over 101F.  Many people will say that they're having fevers when they're a little higher than normal, but 99.8, or even 100.3, can be associated with an extremely long list of possible issues that we just can't assess.

-Dr. West

Dr. West,   Thank you for the explanation regarding fever, I understand it better now. 

Another question...  Is nausea a week after Gemzar typical?  My husband has not eaten solid food since Wed, he was on Ensure the whole time he was in the hospital.  Today he was able to eat a yougart and half a milk shake.  He continues to have nausea, Zofran has helped some.  But he didn't have this much nausea when he was on his first round of chemo (Taxol / Cisplatin).  Last Monday was Gemzar only, the Monday before was Taxotere and Gemzar.  The nausea, to the point of vomiting or dry heaving, since there is no food in him, has been more constant and prolonged during the past two weeks.   Also, ever since he had his lung removed he has a horrible time belching.  The surgeon said this could happen with lung surgery for a few months, could the additional space in the chest be causing his intestines to shift more, and therefore cause more nausea?
Thanks in advance for your answers.  I have found your website extremely helpful.

All bets are off when it comes to nausea - it's difficult to predict how a drug will affect an individual patient.  Though we usually think about platinum as the most nausea-generating, we also give the most aggressive anti-nausea drugs when we give platinum. 

I wouldn't expect this to be a consequence of his surgery.  Pain medications used after surgery may cause nausea, however.  When nausea is so severe that a patient can't eat and is vomiting or having dry heaves, sometimes IV nausea medications are needed to get it under control.  Many patients with severe nausea will require multiple anti-nausea drugs to get it under control.

-Dr. Pinder