What about after the cancer recurs? Mine did at about 7 months. I had a wedge resection. New tumor was morphologally different from first, though both were adenocarcinomas. MSKCC recommended watchful waiting. My oncologist was not comfortable with that and I amd on paraplatin/alimta/avastin.

What do you think?

lindakirk

That’s a unique case, so there’s room for individual opinions. I’d refer back to my thoughts in the forum on this question:

http://cancergrace.org/forums/index.php?topic=526.0

Part of the question is whether it’s felt that the cancers are truly different or the same. If different, you could just approach the two cancers as lightening striking twice and say that you’d treat each one as if the other didn’t exist: if neither is considered high enough risk to treat with post-operative chemo, you wouldn’t give it. If these are the same cancer, then it’s basically a situation of metastatic disease, which is how it appears your oncologist is treating it (the combination you’ve been on would be used for advanced NSCLC). It’s not clear that treating before there is evidence of visible disease in the setting of advanced NSCLC improves the outcome, but perhaps you could think of it as the same thing as high-risk post-operative disease, treating micrometastatic disease in hopes of eradicating the last living cancer cell.

The fact that you’ve received different recommendations from different thoughtful oncologists just shows how controversial this situation is. It’s not going to be possible to get a “right” answer, and I’d be surprised if you got a clear consensus recommendation if you asked 10 experts for their recommendation. We don’t have any evidence to guide us, so we’re left to rely on intuition and principles, and even smart docs will interpret the data vs. holes in the data in different ways.

I wish I could give you a clear answer, but I just don’t see that being possible. We can try to see what Dr. Gadgeel thinks.

-Dr. West

Dr. West

Dr Gadgeel,

I was finally diagnosed with Stage IIb NSCLC - Larg Cell Carninoma (Slow Growing Variant) by Dr. Willima Travis thanks to Dr. West directing me to him after Georgetown and Johns Hopkins fought over if it was NSCLC or SCLC as a post surgical matter.

My onlogist has taken an unorthodox approach to my case with no adjuvant chemotherapy scheduled.

What he wants to do is this: After 3 months a chest x-ray; After 6 months a full body CT scan with contrasts; after 9 months another chest x-ray; after 1 year another full body CT Scan with contrasts followed by a PET Scan. This routine he wants to do for years 1 and 2 and half that the 3rd year arguing that recurrences are most likely to begin taking form within the first two years and manifesting itself in the 3rd.

In an earlier posting and answer by Dr. West, he found this to be a bit different and not folling standard protocol.

My history is one misdiagnosis after another with my tumor 3.25cm in 2004 being ruled an infectious process and when I had another chest x-ray in 2007, it had grown 2% to 3.3cm. Because of this and too many dotors from 2007 to saying it was a Carcinoid tumor, Begign tumor, NSCLC Stage IIIb, A limited SCLC and finally a Stage IIb NSCLC, I am losing faith and fear that mere monitor might cause me to push up daisies sonner than later.

If I don’t die from the LC I am going to die from the anxiety attacks bizarre situation.

We are told to talk with and trust our care to our team and I have and I hope that although what is planned for me although unorthodox is not totally off the hook in LC care.

jrrees2006

jrrees2006,

I’d like to clarify that I would NOT go so far as to say that there’s a real standard protocol to deviate from. I think it is entirely reasonable to individualize follow-up plans, and in prior posts I’ve written on this subject, I indicated that even the professional bodies differ greatly in their recommendations because there is no good evidence that any follow-up plan leads to any better or worse outcomes.

Dr. Gadgeel has conveyed his ideas for what he generally pursues. It is safe to say that there is individual variability. Please talk with your doctor(s) about any issues you have with your proposed follow-up plans.

-Dr. West

Dr. West

I need to clarify that the post I did on follow up of lung cancer patients are guidelines. We as cancer doctors always tailor the guidelines to the particular situation of a specific patient. This requires getting thefollow up done more frequently or less frequently or add tests other than CT scans in the follow up.

Also lung cancer is not one disease. The above guidelines are for Non-Small Cell Lung Cancer, many times referred to as NSCLC. Small cell lung cancer and Carcinoid tumor of the lung would be considered different cancers and the care and follow up of patients in those 2 types of lung cancer is different from NSCLC.

jrrees2006 case also highlights the complexity sometimes encountered regarding diagnosing the specific lung cancer. I am fortunate enough to work with very good pathologists. But there are cases when our pathologists send the biopsy specimen to other expert pathologists to get a second opinion regarding the diagnosis.

Dr Gadgeel

My mom was diagnosed with Stage 1B nsclc and has had a resection of the upper lobe of her left lung. Her doctor now wants to do preventative chemo using cystplatinum and docetaxel. I have read that these two drugs together could be harmful and cause serious side effects, what do you know about them and do you think this would be an effect treatment for her? Is there another combination that might work better and be easier on her? Let me add that there was no lymphnode involvement, all biopsies during surgery (and there were quite a few) came back negative.

dmc72

There are many combinations that could be used, but the ones that are considered optimal by most experts include cisplatin in combination with another agent. In a large trial that is being conducted throughout North America, chemo is being compared to chemo with avastin for patients who are felt to be appropriate candidates for post-operative chemo. The three combinations that are being included as options for these patients are cisplatin/vinorelbine (navelbine), cisplatin/gemcitabine (gemzar), and cisplatin/docetaxel (taxotere). You could consider this to be a vote of confidence that each of these is considered an ideal choice.

They all can be challenging, partly because any chemo can be tough after major lung surgery, and also partly because the cisplatin is often a hard drug. The cisplatin/taxotere combination is definitely an active one, but it can really be challenge to get patients through, and the group at Memorial Sloan Kettering in New York City, one of the largest and most respected cancer centers in the country/world, published a paper describing how infeasible it was for them to get their patients through this regimen post-operatively. Since their patients are often somewhat selected for being unusually fit, motivated, and aggressive, it does suggest that this is likely to be a hard one to use in the real world, so I generally don’t use it for adjuvant therapy. I’ve used both cisplatin/navelbine and cisplatin/gemcitabine and found them reasonable (although I was giving, not receiving).

However, I’d also caution that while it’s not uncommon for us to recommend post-operative chemo to reduce risk for stage I NSCLC patients, that’s still a controversial area where we aren’t sure that the benefit clearly exceeds the risk. I’d encourage you to review some of the posts in the subject archives for lung cancer in the folder about early stage NSCLC, and I’d particularly highlight this one:

http://cancergrace.org/lung/2007/09/28/cons-of-adjuvant-chemo-st-ia-nsclc/

That post describes one side of a debate, and other posts cover some of the perceived advantages of giving post-op chemo.

-Dr. West

Dr. West

I completely agree with Dr. West. I am generally very careful before choosing Cisplatin and Docetaxel (Taxotere) as chemotherapy following surgery for lung cancer because of all the reasons Dr. West mentioned.

Dr Gadgeel