Post Radiation Treatment Options

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This topic contains 12 replies, has 6 voices, and was last updated by  graceabchen 1 year, 11 months ago.

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May 17, 2012 at 12:40 pm  #10450    

blue skies

Got the results of my PET scan (6 weeks) following concurrent low dose chemo and radiation. The results appear to be what we were hoping for: no new sites of cancer or progression and potentially eradicated primary tumor.

My oncologist offers two options for discussion: 3 to 4 cycles of chemo with paclitaxel or docetaxel or a treatment break with scans in 3 months.

I am wondering if another option might be to resume Tarceva as a maintenance treatment, consistent with the thinking I have seen here in previous posts that the radiation has addressed the persistently resistant cells in the primary tumor and that Tarceva may continue to keep the rest of the EGFR sensitive cells in check.

Might this be a realistic third option to consider (a compromise between a blast of chemo and watchful waiting)?

May 17, 2012 at 9:35 pm  #10475    

Dr West

Congratulations on your favorable scan report!

Most lung cancer experts are very unenthusiastic about giving an EGFR tyrosine kinase inhibitor (TKI) after chemo/radiation. There was a large, randomized trial called SWOG 0023 that showed what turned out to be a significant harmful effect from Iressa (gefitinib), and most experts feel that Iressa and Tarceva (erlotinib) are so similar that we should be very wary about giving an EGFR TKI when the best evidence we have is that in this setting, as a maintenance therapy after chemo/radiation, it’s harmful — even if we can’t explain why. There are some smaller studies that suggest Tarceva might not be harmful, but on balance, there is very real concern that we might do patients a disservice by just presuming more is better.

You can read more about this topic in a couple of posts:

http://cancergrace.org/lung/2006/12/16/swog-0023-harm-from-egfr-inhibition/

http://cancergrace.org/lung/2009/08/21/beyond-the-swog-0023-trial-are-iressa-andor-tarceva-harmful-after-definitive-concurrent-chemoradiation-crt/

For that matter, the randomized trial of giving Taxotere (docetaxel) after chemoradiation (sometimes referred to as “consolidation Taxotere”) also showed no benefit from it:

http://cancergrace.org/lung/2007/07/27/challenges-for-consol-taxotere/

We’re still tempted to give additional therapy here, though there isn’t any proven benefit for it, but two options that tend to be least endorsed now are consolidation Taxotere and maintenance Tarceva, for the reasons I described above.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

May 17, 2012 at 10:52 pm  #10484    

Dr. Weiss

This conversation is typically had after low-dose chemo concurrent with radiation for stage III cancer. Here, the debate is whether the weekly chemo is adequate for distant control of cancer. Some oncologists argue for two cycles of “full dose” chemotherapy following and a smaller minority argue for even four cycles. As Dr. West notes, we know that consolidation with taxotere or a TKI doesn’t help. We don’t know if two agent chemo, including a platinum drug does help, but here there’s at least a lack of negative data and there is a common-sense rationale to hope that it does help.

It may be worth pointing out that blue skie’s tagline describes a very different situation, one of having received 3 lines of prior therapy for metastatic cancer. If the chemorads was just to the primary tumor and not to sites of spread, then the goal of this therapy was not curative, but rather to give aggressive control to the primary area that was felt to be the biggest problem. From the sounds of the post, it sounds like it worked well and I congratulate you. I further congratulate you’re thinking–you’re critically asking, “If I do something more, what should it be and can it really help or not?”

Based on paragraph 3 of your post, I think that the rationale for tarceva might be that it previously controlled the cancer at the spots other than the one that was just radiated. Therefor, if the progressive area has been obliterated, could tarceva help again? Please correct me if I’m misinterpreting the question. If I’m not, I’ve addressed this general principal recently on GRACE at http://cancergrace.org/lung/tag/acquired-resistance/ If the radiated spot really is the only one that was growing when you progressed on tarceva, then the rationale for restarting is reasonable. However, another line of thought might ask that given the good scan, whether you might not accrue similar benefit from observation, with consideration of restarting tarceva at next progression. The trial that I describe mandates that it be the first trial after progression on tarceva. The reason is that you otherwise can’t know for sure which sites are truly tarceva resistant and which are not. Further, the SWOG data that Dr. West cites suggests possible harm from TKIs like tarceva after chemorads; in contrast, the trial that I described uses cyberknife without chemo.

I hope that you do not interpret my post as arguing for or against any particular action. Rather, I’m trying to help you to explore the hard data that exist to help you to educate your decision. I hope also that it helps.


Jared Weiss, MD
Lead Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or University of North Carolina. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

May 18, 2012 at 4:46 am  #10495    

blue skies

Thank you, Dr. West and Dr. Weiss. This is exactly the kind of thoughtful and informed response I was hoping for…though I was pretty happy that my primary oncologist and doctor at MSKCC both thought resuming Tarceva could be a good approach.

Dr. Weiss, I believe that you correctly interpreted my situation. The primary tumor is the only spot that progresed (with a vengence when it did) over the last two years. The femur was radiated early on and has been stable. No new mets anywhere.

Fortunately, I have time to reread all those GRACE summaries and your responses again to better understand and weigh the benefits and risks of doing something or doing nothing. I want to preserve my treatment options for as long as posible and don’t want to make anything worse in the meantime! I am very appreciative of having had access to all this information due to your excellent educational efforts.

Thank you so much again for your response. It will help me make the best decisions possible and I can’t imagine how I could ever do that without this site and your dedication to this important effort.

May 18, 2012 at 6:39 am  #10497    

double trouble

Hi blue skies. I don’t mean to hijack your post, but I do have a question here. Does this mean that TKI’s will be excluded for the remainder of the patients treatment life, or are you saying that it is just contraindicated immediately after chemorad?

Blue skies, I am on a treatment break. I know there is a lymph node that started showing very minimal uptake, so it’s hard to do nothing at times. On the other hand, this has given me the opportunity to try and ignore thoughts of cancer and all that goes with it, at least for a while. And the break has given me and my primary physician time to address all those other little health issues that co-exist (mammogram, pap, upper endoscopy (Barrett’s Disease is GONE! Maybe due to doubling up my PPI, maybe the Cisplatin helped out), physical therapy and finding the right drug for arthritis flares, nerve studies for peripheral problems, etc.) so that if I do have to put my battle gear on again for the cancer, I can focus on that and not be bothered by aches and pains that are unrelated to the cancer. Im addressing all the little things while on my break.

So, I guess I’m just trying to relate to you that a treatment break is like being able to take a deep breath and catch up on your regular life. You would be closely monitored throughout. Yes you will feel like you should be “doing something” at times, but really, your body has been through so much! A break gives you time to also focus on your diet, and add some exercise to your routine, and really build up your strength. Hopefully you won’t need it for a “next round”, but if you do you’ll be at your best and ready for the fight.

I’m not trying to give advice about whether you should take a break or seek more treatment, I just wanted you to know how I see things during my break. I still have the cancer in the back of my mind every day, and everything I do is with the thought that I will be better prepared for the next challenge. I know that for some of us it is impossible to consider ourselves cured. We know we’re playing Whack-A-Mole, just waiting for the next lesion to light up and declare itself. I think the treatment breaks are really a very good thing. Time to relax and refresh, and build strength.

We’ll all be here to cheer you on, whether on a break of on a new treatment. I’m so happy for you about the results of your scan! Hang in there, and keep advocating for yourself! And keep us posted.

Debra


09/10 CT Bil. GGO’s 12/10 L L VATS Segment Adeno/BAC Kras+ 1st Primary Stage Ib
05/11 CT L Stable RU 1.3 cm nodule, 1r & 2r LN 08/11 PET/CT L Stable, mild uptake in R nodule, LN
09/11 EBUS N1, N2 LN Adeno+ 2nd Primary Stage IIIb
10/11 Start chemorad Cisplatin 11/11 Stop chemorad 4 cis/38Gy blood counts
12/11 PET/CT FDG neg 03/12 PET/CT Stable R nodule R hilar SUV 3.4 06/12 Growth R hilar SUV 9.5
07/12 Mayo recommends thoracotomy pneumonectomy EBUS R Hilar Adeno+
08/15/12 Brain MRI Normal 2nd Opinion Duke recommends VATS pneumonectomy
09/12 PET/CT hilar growth, new R 2.2 SUV 1.5 by 2 cm Hilar LN Kras+
Duke Mediastinoscopy R Lung Unresectable, Bronchoscopy #7 LN Adeno+ ALK+
10/12 HRCT 4 RUL nodules (3new) enlarging R Hilar
12/12 PET/CT 12/19 Start Xalkori 02/13 Decreased FDG R Hilar. RUL collapsed 05/13 Stop Xalkori begin rad x10 30gy
05/13 Hospital 6 days postobstructive pneumonia, cavitary abscess, complete rad
06/13 Bronchoscopy RUL RML blocked 07/13 PET/CT Decrease in size and SUV Hilar 09/13 Decrease in size and SUV Hilar, infection resolving

May 18, 2012 at 6:54 am  #10498    

graceabchen

This is very educational, particularly for current tarceva users. Blue skies, thank you for sharing your experiences and asking key questions. Dr. West and Dr. Weiss, thank you for giving your best advice.
Thanks, AB

May 18, 2012 at 9:12 am  #10501    

Dr. Weiss

No, tarceva is not permanently contraindicated. All that we know for sure is that immediately after chemorads, EGFR TKIs seem to do more harm than good. Perhaps when given right after radiation, they impair the efficacy of the radiation. If we were to scientifically speculate, we might hypothesize that if the TKI keeps some of the cancer cells out of cycle (not dividing) at the time that the radiation is still doing its damage (at least a few weeks after the actual radiation beam finishes) then it could protect the cancer cells. This makes scientific sense because internalization of EGFR receptor leading to a pause in cell division is one of the mechanisms by which some lung cancer cells protect themselves against radiation.


Jared Weiss, MD
Lead Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or University of North Carolina. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

May 18, 2012 at 9:30 am  #10502    

FaithAndHope79

Thank you all for the valuable and straightforward discussion.

May 18, 2012 at 11:58 am  #10507    

graceabchen

I went through the reports cited by Dr. West regarding the question whether TKI is worse than chemo as a maintenance drug after the combined chemo/radiation treatment. Contrary to the earlier SWOG 0023 findings, more recent trial results seemed to slightly favor tarceva. I understand that EGFR was not a factor considered in all these trials. Knowing that neglecting the EGFR factor can greatly skew the trials results involving TKI, EGFR+ patients probably should not worry too much about these results. AB

  • This reply was modified 1 year, 11 months ago by  graceabchen. Reason: typo
  • This reply was modified 1 year, 11 months ago by  graceabchen. Reason: Typo
May 18, 2012 at 12:44 pm  #10510    

double trouble

Thank you Dr. Weiss for answering my question about Tarceva.
Debra


09/10 CT Bil. GGO’s 12/10 L L VATS Segment Adeno/BAC Kras+ 1st Primary Stage Ib
05/11 CT L Stable RU 1.3 cm nodule, 1r & 2r LN 08/11 PET/CT L Stable, mild uptake in R nodule, LN
09/11 EBUS N1, N2 LN Adeno+ 2nd Primary Stage IIIb
10/11 Start chemorad Cisplatin 11/11 Stop chemorad 4 cis/38Gy blood counts
12/11 PET/CT FDG neg 03/12 PET/CT Stable R nodule R hilar SUV 3.4 06/12 Growth R hilar SUV 9.5
07/12 Mayo recommends thoracotomy pneumonectomy EBUS R Hilar Adeno+
08/15/12 Brain MRI Normal 2nd Opinion Duke recommends VATS pneumonectomy
09/12 PET/CT hilar growth, new R 2.2 SUV 1.5 by 2 cm Hilar LN Kras+
Duke Mediastinoscopy R Lung Unresectable, Bronchoscopy #7 LN Adeno+ ALK+
10/12 HRCT 4 RUL nodules (3new) enlarging R Hilar
12/12 PET/CT 12/19 Start Xalkori 02/13 Decreased FDG R Hilar. RUL collapsed 05/13 Stop Xalkori begin rad x10 30gy
05/13 Hospital 6 days postobstructive pneumonia, cavitary abscess, complete rad
06/13 Bronchoscopy RUL RML blocked 07/13 PET/CT Decrease in size and SUV Hilar 09/13 Decrease in size and SUV Hilar, infection resolving

May 18, 2012 at 3:13 pm  #10520    

blue skies

It is so great to be able to have this kind of discussion to build understanding of the many nuances of the art of oncology with people who have a very direct interest.

Thank you, Debra, for your perspective. I have followed your posts the last two years and consider you a wise and thoughtful virtual friend. I am always pleased to get your perspective and experience. It really is hard to consider a treatment break, but I am also concerned about “saving up” my more toxic treatment options so the journey and the battle can continue for as long as possible. I can alswo appreciate the opportunity to stop feeling so dragged out by chemo or skin issues and being able to find the capacity to focus on the more mundane health issues.

May 18, 2012 at 5:40 pm  #10521    

Dr West

I should also say that my comments are more directed toward chemo/radiation for stage III NSCLC, so the question of when to be on ongoing treatment for advanced disease is appropriately considered as a somewhat separate question. As AB pointed out, the SWOG 0023 trial was a molecularly unselected population, and we might presume that patients with a known EGFR mutation would be more likely to benefit and less likely to be harmed. The only challenge to this presumption is that, in the NCI-Canada-led BR.19 trial of post-operative Iressa vs. placebo, not only the patients with EGFR wild type (no mutation) but even those with an EGFR mutation showed no benefit. In fact, both groups showed a trend toward harm with Iressa compared with placebo, and the trend toward harm was considerably more pronounced in the subset with an EGFR mutation. It’s results like these, where we would have presumed one result but actually saw the opposite, for reasons we cannot explain, that make me wary about extrapolating too much based on what we presume should work but hasn’t been looked at carefully.

More on that here: http://cancergrace.org/lung/2010/07/25/post-asco-disc-of-br19/

If treatment is being given to control the disease, prolong survival, but we aren’t feasibly treating with curative intent, my general strategy is to pursue to least aggressive approach needed to likely keep disease more or less stable and the patient without symptoms for the next 6 months or so — with ongoing recalibration of plans as needed. What this means in practice is that if a person has no evidence of active disease or very indolent, asymptomatic cancer, I’m dubious about the value of treatment, or with more aggressive treatment than needed to control the disease. There just isn’t evidence that treating now is better than giving the same treatment later in metastatic disease if the person can be monitored closely enough to intervene while they have the same performance status.

-Dr. West


Howard (Jack) West, MD
Medical Oncologist

Views expressed here represent my opinion, not those of GRACE or Swedish Cancer Institute. This information does not constitute medical advice and is intended to supplement and not replace medical information provided by your doctor.

May 18, 2012 at 9:01 pm  #10522    

graceabchen

Dr. West: Thank you for pointing out the BR-19 trial. Yes, I am surprised that iressa actually was worse than chemo as post-operation maintenance for non-advanced patients (stage I to III) with positive EGFR. Since the number of EGFR+ patients in that trial was small, the result is not without uncertainty. The situation could be similar to the SWOG 0023 trial, which showed iressa worse than chemo as a maintenance drug after the combined chemo/radiation treatment for stage III. However, more recent trial results seemed to slightly favor tarceva, as indicated in the 2009 reference you gave earlier. Thanks, AB

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