EGFR TKIs for an older patient with ECOG 4?

Portal Forums Cancer Treatments / Symptom Management Symptoms/Supportive Care for Patients EGFR TKIs for an older patient with ECOG 4?

This topic contains 14 replies, has 4 voices, and was last updated by  remyhelios 3 years, 6 months ago.

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April 18, 2014 at 3:43 pm  #1263314    

remyhelios

Question:
Are older NSCLC patients with ECOG performance status 4 considered for EGFR TKIs ?
If so, how can I find a Medical Oncologist willing to take me as a patient? I’m in Newark, D.E.

Patient Summary:
Male, 80+ years old, non-smoker, Diagnosed in mid-March 2014 based on CT, PET scan, bone scan as Stage IV primary Lung Cancer (upper right lobe, 38 mm) at a regional medical center. (no brain or internal organ metastasis but 4+ bone sites involved) Tumor was probably a slow growing one based on medical history. (patient had some un-followed punctate nodules starting in 2003) Local Medical Oncologist stated since there are no treatments suitable for an ECOG 3 or 4 patient a biopsi only introduces risk and the patient is better off with \”best supporting care\”. Tumor DNA typing, EGFR TKI class of medications were not mentioned. Only Chemotherapy was mentioned.

Patient later read about all FDA approved treatments for his Stage IV lung cancer including first line Erlotinib. Even though he does not have some typical characteristics of EGFR+ patients, due to Asian ancestry and non-smoker status he feels there could be a small chance he is EGFR+. He knows about the side-effects of EGFR TKI class of drugs and willing to go through treatment if it can enhance his quality of life and performance status. He is aware of at least two articles describing promising results for EGFR+ patients in his age group with similar ECOG performance status.

Patient understands that without a biopsi his diagnosis of NSCLC is just an educated guess based on his medical history and imaging studies. He is willing to do a biopsi immediately if he is certain an Oncologist would take his case. He is also wondering what type of biopsi would put him at lowest risk for a collapsed lung given the location of his tumor. Thank you in advance.

April 18, 2014 at 7:50 pm  #1263318    
Dr West
Dr West

It’s really a judgment call whether the probability of an EGFR mutation is high enough to pursue a biopsy for that purpose, vs. the risk of a serious complication from the biopsy. The interventional radiologist who would do the biopsy is the person who would need to make the assessment of the safety. A fine needle aspirate MIGHT be able to obtain enough tissue to do EGFR mutation testing, but a core biopsy is more likely to get more tissue and more likely to cause a collapsed lung.

Bear in mind that even though we are certainly inclined to favor giving an EGFR TKI if someone has an activating EGFR mutation, it’s not miraculous. The response rate is 60-75%, not 100%, and the responses last a finite period of time.

If he were previously far more robust 6 months ago, there is reason to think that his poor performance status is from the cancer and could potentially be rapidly reversed with an EGFR inhibitor if he has an EGFR mutation. However, if he was frail before 6-12 months ago, then even effective treatment wouldn’t be expected to dramatically improve things.

Good luck.

-Dr. West

April 20, 2014 at 10:20 am  #1263328    

remyhelios

Thank you for your reply Dr.West.

I’m glad that he may be considered for treatment if the prerequisites are met.

His performance status decline took place within roughly 6 months. He was ECOG PS 0 until September 2013. Bone pain in his left hip and fatigue forced him to stop his daily walks. He declined to ECOG 2 by end of January 2014 and an ECOG PS 3 by late February. Now he is a 4.

I think he understands the chances of having the mutation and achieving disease control are less than 25% or maybe lower. By nature he is very positive/optimistic so willing to take a chance to be able to maybe get out of bed. His mind is still sharp. Oxygen Saturation/breathing and pain are both under control and stable.

I will seek a consult with an Interventional Radiologist. Tumor size, lesion to pleural distance and the needle pleural angle seem to be the risk factors in Pneumothorax and bleeding. Hopefully after a review his IR would give the go ahead. He also has mild to moderate COPD which increases the biopsi risks.

The other idea that may control the biopsi risk factors is to do a biopsi on a bone lesion first. I’m not sure if EGFR typing can be done on such a sample but guessing it should at least let us know if the tumor is NSCLC , adenocarcinoma, … This may help validate taking a risk with a second biopsi on the lung tissue.

April 20, 2014 at 11:20 am  #1263329    
JimC Forum Moderator
JimC Forum Moderator

You’ll need to discuss the possibility of a bone biopsy with your doctor, but as Dr. Pennell has written:

“The only caveat to the bone biopsy, which you might want to make sure the doctor asks about beforehand, is that bone biopsies can be hard to use for molecular tests like EGFR and ALK. Bone is too hard to cut into slices for the microscope, so it undergoes a process called “demineralization” to soften it up. This process destroys DNA, which is what is tested for EGFR mutations and ALK translocations. This has come up with my patients more than once where we were unable to test their biopsies and had to go after something else.

One alternative is a bone marrow “aspirate” which sucks out some of the tissue in the marrow of the bone but doesn’t require demineralization.”http://cancergrace.org/lung/topic/biopsy-of-left-iliac-bone/#post-6451

Earlier in the same thread, Dr. West discussed the procedure itself:

“The risks are pain, bleeding, and infection as the leading ones. I would say that it’s very hard to imagine that the biopsy itself would lead to any meaningfully increased risk of a fracture; I certainly have never heard of a higher incidence of fractures of bone lesions just from a small biopsy.”

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

April 22, 2014 at 8:56 am  #1263335    

remyhelios

Thank you for the response JimC. Very important information. This is a wonderful site.

Late today we will have a followup evaluation with the local IR to take a new CT and assess the FNAB vs. CNB risks.

Two quick questions that may come up during the consult:

1- what type of referral we need for a a bone marrow aspirate? (what type of a doctor is needed)

2- Does the patient have a choice in terms of which pathologist and DNA lab are used? I hear DNA testing quality varies. I think we have one shot to get this right and if there are any suggestions on where to send the samples please let us know.

UPenn and Fox-Chase, Jefferson are the closest. Johns Hopkins and U Maryland are also within reason. I’m guessing the one’s designated as Comprehensive Cancer Centers by NCI do all the tests in house.

April 22, 2014 at 12:27 pm  #1263341    
catdander forum moderator
catdander forum moderator

References standards differ according to insurance and hospital standards. An interventional radiologist would be the doctor to perform that type of procedure though guessing at how much useable tissue may be difficult to guess at beforehand.
You have the right to do with your tissue as you wish, though most large teaching/research hospitals use quick turnaround labs and some do there own. It depends.

I wish comfort for this man and hope you get what you need,
Janine

April 22, 2014 at 7:12 pm  #1263348    
Dr West
Dr West

Janine’s right about those issues. Sometimes a pathologist or medical oncologist does a bone marrow aspirate, but when you’re going for a specific spot, it’s most likely to be an interventional radiologist.

All of the places you mentioned are very good, and I’d consider U Penn and Johns Hopkins to be particular centers of excellence in lung cancer. Dr. Corey Langer at U Penn has a particular expertise in management of elderly and more frail patients, so it might be especially helpful to try to get an opinion from him…though he’s a major luminary in the field, so it may be like getting an audience with the Pope.

Good luck.

-Dr. West

April 24, 2014 at 12:43 pm  #1263395    

remyhelios

Thank you Dr. West. and Janine for the replies.

We did a followup CT of abdomen and pelvis with contrast recommended by the local IR. The only thing I heard back was that he still needs to do the lung biopsi. My father does have a pelvic lymph node which lit up in a previous PET-Scan and more than one bone lesions. (lower back) Still waiting for the official IR “consult” to know why secondary sites are not a good candidate for a biopsi in his case.

Dr. West, thank you for mentioning Dr. Corey Langer. He has so many publications on the subject. I will try my best to get an appointment with him or at least see someone sharing his interest in treating the elderly and frail.

Since we do not have an official Oncologist, I don’t know which other genetic tests in addition to the EGFR are warranted in his case.

Is testing for ALK in order? any point in testing for RET, ROS, HER2 if there’s enough tissue left?

April 24, 2014 at 4:53 pm  #1263400    
catdander forum moderator
catdander forum moderator

Normally if someone with a non-squamous nsclc doesn’t test pos for egfr an ALK test is done then possibly ROS though ROS is quite rare ROS and ALK are treatable with ALK inhibitors such as crizotinib.

Bone is notoriously difficult to biopsy and many tumors are positioned so to be hard to reach. You can get a better idea as to why you father is having problems from those involved.

April 25, 2014 at 3:25 pm  #1263419    

remyhelios

Posting an update on my conversation with the local Interventional Radiologist’s office. Don’t know what to do at this point. I feel with every day of delay and unnecessary obstacles his chances of treatment diminish.

Our local IR only communicates through his Nurse Practitioner. The one exception being a quick conversation on the day of the biopsi. We met with the NP and she said they would only go after the primary lesion in the Right Upper Lobe. Explaining that they are not sure that the bone lesions are cancer. (her statement is confusing since we did both a PET scan and a bone scan so there should be limited doubt as to location and extent of bone involvement)

Then I asked about the relative risks for the biopsi as opposed to a bone aspirate. She did not know and said there is no risk with the lung biopsi. (which is surprising, because in the literature I see anywhere from 17% to 40+% for people with complications such as COPD).

Then we discussed the biopsi type. I was told they initially only do a FNAB not a CNB. I asked her in what percentage of the cases this yields enough tissue for a tumor genetic typing. She said we don’t order the testing upfront. Our doctor does the FNAB and after 3-5 days the pathology report comes back. Then your Oncologist orders EGFR, etc. Given that some studies indicate the risks of FNAB and CNB are similar, I thought maybe we should do a CNB in the first place if maybe up to 2 tumor DNA typing tests are on the horizon.

We still don’t have an Oncologist so don’t know how to navigate this. Expecting a 2 weeks delay in getting an appointment with an Oncologist who would see patients with a poor performance status. In order to save time, I was hoping to show up to the Oncology appointment with the biopsi report, genetic tumor type and our DICOM CD of all imaging studies in hand to discuss treatment options.

April 25, 2014 at 7:28 pm  #1263423    
Dr West
Dr West

I’m sorry it has been such a frustrating time. Usually the doctor who has been managing things up to now, such as a pulmonologist or even a primary care physician, can help shepherd people up to the point of the biopsy and then referral to an oncologist as needed. That generally isn’t left to the patient and their family to self-manage.

Good luck.

-Dr. West

May 7, 2014 at 4:57 pm  #1263651    

remyhelios

An update on my fahter’s biopsi.

I met with the local IR prior to my father’s Right Upper Lobe biopsi. He said 45% risk of pneumothorax with FNAB in his case My father went ahead with the biopsi. His lung partially collapsed and he had a chest tube for 72 hours. He is fine now but it was a painful experience for him.

Now, 7 weeks after the initial diagnosis as Stage IV LC by our Radiologist and Oncologist at the local hospital and their recommendation to go to a hospice because there’s no treatment option available, we have a biopsi report. Biopsi came back as Granulomatous inflammatory tissue. It was also AFB positive. A subsequent Sputum sample was also positive for TB. We have to wait 6 weeks for the culture sample. He is on TB therapy as of yesterday. We’re pretty convinced that he has an active TB infection. Our whole family will be tested. In his youth he traveled a lot and also lived in an underdeveloped country so maybe this is a reactivation.

Even though the symptoms of Lung Cancer and TB have overlaps (e.g. fatigue, weight loss, cachexia) After reading Dr. West’s post on False Negatives, it seems my fahter’s biopsi had at least 2 out of 5 elements common in a False Negative.

http://cancergrace.org/lung/2012/04/22/false-neg-biopsies-of-lung-nodules/#more-9274

I’m thinking maybe he had a False Negative on this solitary “tumor”?

He also had a bone scan and PET scan at initial diagnosis in mid-March. Both showed multiple areas of “metastases” from the presumed primary tumor in the Right Upper Lobe. Now our Internist (not the Radiologist) is attributing everything to TB.

I know infections and inflammatory processes also light up in these imaging studies, but how can we be sure that everything is attributable to disseminated TB? I’m specially worried about the bone scan study which showed back of his skull, pelvic bone, ribs and hip with tracer activity. Is there a place that I can send the imaging CD for a second opinion?

May 7, 2014 at 5:58 pm  #1263652    
JimC Forum Moderator
JimC Forum Moderator

I don’t think you can be certain that everything is attributable to TB, but it is certainly possible that what is seen in the lung is TB, and perhaps there are alternate explanations for the bone “mets” (for example some form of inflammation such as arthritis). Perhaps you can ask your father’s doctors (including the radiologist) to review the bone scan findings in light of the TB diagnosis.

It is also possible that he has TB and lung cancer, with a false negative biopsy on the “tumor”, so his doctors will want to monitor his overall health while on TB therapy, and repeat imaging. If he feels better and the next scan shows resolution of the “tumors”, then TB will likely be the correct diagnosis.

I don’t think that just sending the imaging CD for a second opinion would be all that valuable, since the results of the biopsy and other medical information about your father are also relevant to diagnosing his condition. Instead, if you want a second opinion, it would be preferable to make an appointment with another doctor to review all of your father’s medical records and examine him in person.

In the meantime, I’ll be sending positive thoughts that this is “only” TB and that his therapy will clear it up soon.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

May 7, 2014 at 9:51 pm  #1263657    
Dr West
Dr West

As Jim indicated, a second opinion on the imaging won’t give the diagnosis.

It’s absolutely possible that there is more than one thing going on. One way to evaluate this would be to do a biopsy on one of the more accessible bone lesions. However, I don’t know if that’s feasible or clearly advisable if he is very frail. Perhaps if he improves with treatment for TB, he’ll be strong enough to pursue more of a workup of the bone lesions to see whether he has a concurrent diagnosis of cancer as well as TB.

Good luck.

-Dr. West

May 8, 2014 at 7:09 am  #1263659    

remyhelios

Thank you JimC and Dr. West for your replies.

We will give him time to hopefully respond to TB therapy. Given the advanced stage of his TB and so far unknown bacterial type that’s not a given. If he starts getting stronger it opens up more options such as a bone biopsi.

Your valuable, objective and wise responses have helped us through a difficult time. Thank you.

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