GRACE :: Lung Cancer

Congratulations, your tumor is stable! So… is that good news or bad news?

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There is nothing more disheartening to the patient, and quite frankly for the treating oncologist, than have to hear (or say) the words “I’m afraid the treatment isn’t working”. The scientific term is “disease progression”, but the reality is that the cancer is growing despite the treatment and it doesn’t take an expert to know that isn’t good news.

However, next in line in the statements that seem to generate a decided lack of enthusiasm is “Your cancer is stable”. Stable doesn’t sound so bad, does it? The tumors haven’t changed, nothing is growing, there are no new lesions to suggest progression, but all of these reassurances often seem to fall on deaf ears. Sure, we’ll keep going with the treatment, but it MUST be bad that the tumors didn’t shrink, right? I sometimes think my patients feel I’m being dishonest with them when I get enthusiastic about something as ambiguous as disease stability.

Of course, it isn’t hard to understand this feeling. Who wouldn’t want a clear sign that the cancer is dying, that the treatment is working. Patients want their cancer to be gone, and watching it disappear must be very heartening. I also admit that there is little in my job as gratifying as looking over the scan and seeing that the tumors have all shrunk, what is known as an “objective response”. I’ll often pull this type of scan up on the exam room computer to show off my treatment prowess: look at what I did! But is a response really that important?

Let’s look at tumor responses for a minute. If the tumors shrink but don’t disappear this is called a “partial response” (or PR) and if they disappear entirely this is called a “complete response” or (CR). Response rates have been the traditional marker of whether a chemotherapy drug is effective, and historically drugs that did not cause tumors to shrink have been abandoned. Stable disease (SD) was usually reported separately, if at all, and has been regarded by some as the poor man’s response rate. If your trial failed and there were no responses, at least you can report a high SD rate and maybe someone will think your drug is good for something!

But this concept has changed a lot in the modern era. Trials utilizing so-called “targeted agents” have even reported improvements in overall survival with few or any objective tumor responses. One good example of this is the randomized trial of Nexavar (sorafenib) in hepatocellular (liver) cancer. This trial showed a 3 month improvement in overall survival in patients with HCC treated with sorafenib, despite only 2% of patients “responding” to the drug. Trials like this one have raised the question of just how important response rate is to determining if a drug is helpful or not.

But that was for these new, fancy-schmancy drugs like Nexavar or Tarceva. What about ordinary chemotherapy? Well, at the 2009 ASCO meeting in Orlando there was a poster that I found fascinating but I haven’t heard too much buzz about. A group of investigators from Japan, led by Dr. Hirokazu Watanabe, looked at the survival of advanced NSCLC patients treated with 4 different platinum-based chemo regimens as part of a clinical trial and related the survival to whether the patients had a response, stable disease, or progressive disease as their best outcome.

The results were very interesting. Patients who had an objective response to chemo had a median survival of 16.1 months, pretty good for an advanced lung cancer trial. The patients who had progressive disease had a median survival of only 5.5 months, which was (obviously) significantly worse. But what was so interesting is that the patients who had only stable disease had a median survival of 15.2 months, which was not statistically different from the responders. The survival at 2 years was 33% in the SD group compared to 30% in the responders, raising the question of just how important it is to have actual tumor shrinkage. At least in this trial, it didn’t seem to matter at all.

The concept of benefit in patients who have stable disease isn’t really new, of course. In recent years studies have been reporting something called the “Disease Control Rate” which is the response rate + the stable disease rate. But for patients, I think it is harder to grasp that it is really just as good that the cancer is exactly the same as to have it shrink. Lately I have started being very specific before starting treatment that all we are really hoping for is to keep the cancer from growing (something that is actually more common than getting a response), and that this SD is every bit as good as a response. Hopefully this tempers the disappointment just a little when stable disease is the result.

Of course, this won’t stop me from pulling up the scans to show my patients when the tumors do shrink. It makes a good show, it feels good for us both, and everyone wins. Stable disease is kind of like that vegetable you hate (brussel sprouts, anyone?); you know in your head that it’s good for you, but that doesn’t make it easier to swallow.


9 Responses to Congratulations, your tumor is stable! So… is that good news or bad news?

  • mo wanchuk says:

    Perfect timing for this post as I just received my pet scan report today after 6 weeks of taxotere(my fourth-line treatment for 39 month old stage iv nsclc). I’ve always assumed that stable is good when the lesions aren’t compromising major organs. My spinal lesions at L5-S1 and lower sacrum remained the same size but the uptake decreased. My lesion on a lymph node shrunk slighly (42 mm x 17mm from 41mm x 23 mm)but the uptake increased slightly. The radiology report classified me as stable. For all intents and purposes, it appears as if that’s just as good as actual tumor shrinkage. I’ve always been disappointed at never hearing “NED“, but have long given up on that ever happening unless there is some major breakthrough.

  • AG says:

    Thanks for that perspective Dr Pennell. Cancer is a disease that can quickly teach you the value of being pragmatic. Especially since the state of the art in treatment protocols can’t achieve a cure (or even reasonable survival) for many types of cancer. In those cases “stable” can be one of the sweetest words you’ll ever hear. We seem culturally conditioned to negatively perceive anything less than perfection, complete victory, or other deviations from an ideal standard – real or artificial. There’s value to this since it fuels continuous improvement in many worthwhile endeavors. But there’s room for a more balanced view of life where you learn that “good enough” is often all you need…

  • Dr West says:

    Yes, a complete response is an amazing and very welcome development for advanced NSCLC, but it’s really a very, very high bar for that setting. Most oncologists think of the term “NED” (no evidence of disease, for those who are unfamiliar with it) with regard to resected lung cancer or a locally advanced cancer (SCLC or NSCLC) treated with chemo and radiation, and then potentially cured.

    Though complete responses in advanced NSCLC are possible, they occur only about 1-2% of the time. It’s important for those with a response or stable disease to know that this is still a favorable result, and that a complete responses is a rare bonus.

    -Dr. West

  • catharine says:

    Dr. Pennell –

    Thank you for that excellent perspective. My usually taciturn/stoic oncologist actually seemed happy when he was able to show me some lung tumor shrinkage and the (potential) absence of a previous liver tumor on my last scan, so I understand that feeling. It was fun to see him in a positive mood. As a cancer patient, I was happy to view these results too, but my little researcher’s voice kept whispering “measurement error” and thus tempered my response a bit. I understand that objective response is statistically less likely than stable disease. You’re right that it’s more realistic to start with stable disease as the more likely outcome and then celebrate when/if tumors shrink. When I envision successful treatment, I imagine the cancer cells dying off and shriveling away never to return, but I’ll accept that they simply do not grow any more. Either outcome beats the alternative.
    – Catharine

  • Incurable optimist says:

    In the case of lung cancer, I’d say the acceptability of stable disease might be quite closely related to symptoms.In my own case I also have breast cancer, and have opted for hormone treatment (anastrazole) rather than something more radical, with a view to keeping it under control – there seemed little point in undergoing unpleasant curative treatment in the presence of the lung cancer .This strategy appears to be working.

    The breast cancer itself has never caused any symptoms, and the side effects of the anastrazole are minor and easily managed. I would be quite happy with this controlled stability as a long term approach to breast cancer at my age (62) even if I didn’t have lung cancer.Younger women would perhaps see things differently – and the treatment is a little too new to have much idea of how long it will work,of course.Stability would also to me be more than acceptable with the lung cancer, providing the symptoms were at a maneageable level.

  • fillise says:

    In the last 30 months “stable” has become my few favorite word. After mom’s first course of chemo, her primary shrank by one third and then just sat there “stable” for 18 months. It was a great time where my mom was not on any treatment, felt pretty good and was able to lead a normal life. I learned that “stable” is indeed a beautiful word.

    The response to that word may have something to do with expectations. When mom got her dx, the first words out of her mouth were “I guess I’m a goner.” After she finished her radiation and was meeting with her oncologist four weeks later to learn about her chemo, he told her that he couldn’t cure her, but he thought he could control the disease. She told me later that was the first time she felt like she wasn’t under a death sentence. So for her “stable” means control and that means success.

    Sunday marked the 30th month since my (then) 76 year-old mom was diagnosed with stage IV NSCLC. She finished a second course of chemo in March and heard the word “stable” again in April. She goes for her three-month scan in a couple of hours and I can promise you that I will be thrilled to hear “stable” again. She will too.

  • lshljs says:

    Dear Dr. Pennell,
    You have actually made my day. My husband has etx SCLC, after the first two chemo treatments, the scan showed a 50% reduction in the ca, two more treatments and then a scan that showed stable disease. I was SO disappointed. I have walked around for the last month being sure that that meant that the minute we stopped chemo, it would definitely grow again. I know that is stil very much a possibility but I now know that I can again have some hope of having a break or maybe some time with no treatment. When I have some hope, I am less fearful and way more functional. He actually feels good on most days except for those few days right after chemo and he is having a good summer. Rx # 6 next week and is the last for now. I am going to be happy about stable, take it as a good sign and stop worrying about what’s next, at least for now.
    Thank you so much, Sue

  • Dr West says:

    I also feel very satisfied telling my patients about stable disease, especially if I get to tell them this month after month after month, and they’re tolerating treatment well.

    -Dr. West

  • kumar9211 says:

    SCLC After 6 cycles of chemo (ETOPOSIDE + CARBOPLATIN 1 cycle = 3 days) no change in size of tumor is observed. Doctors say its stable disease. I Don’t know what should be my reaction on that. Shall i be happy or shall i be disappointed. Now my oncologist is suggesting me for radiation. I hope cancer goes away with radiation. I will highly appreciate your views on radiation therapy.

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