NED after chemo treatment, hold off on Tarceva?

Portal Forums Lung/Thoracic Cancer EGFR Inhibitors NED after chemo treatment, hold off on Tarceva?

This topic contains 5 replies, has 3 voices, and was last updated by  DJ Nikkam 2 years, 5 months ago.

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March 3, 2016 at 9:35 pm  #1273137    

sidekick4mom

Hi,

Hi, I’m posting this on behalf of my 60 year old mother who was diagnosed with Stage IV adenocarcinoma back in February. She’s Asian and has tested positive for EFGR mutation.

After her chemo treatments, she was just recently scanned and it showed no signs of cancer and the doctor declared her in remission, which is great news!

However, she had been scheduled to begin Tarceva this month as her oncologist was switching her off the chemo. But we didn’t know she would have responded so well to the treatment so now I am wondering whether it’s still a good idea to start her on Tarceva.

I’ve read some opinions that indicate it may be better to wait on the starting the medication. The logic it seems is that if she started on it later when it’s more necessary, resistance would then develop later rather than if she got on it now. Has anyone here ever heard of this? Or maybe its better to get on Tarceva for maintenance and prevent recurrence?

I know there’s probably no sure answer, but what’s the prevailing wisdom in such a situation as hers?

March 4, 2016 at 8:14 am  #1273139    
JimC Forum Moderator
JimC Forum Moderator

Hi,

As Dr. Creelan stated in your previous thread, there really isn’t a right answer, but in a situation where treatment has left no evidence of cancer, many oncologists would hold off on Tarceva until there is something to treat – visible signs of cancer. If you begin Tarceva now, there will be no way to measure whether it is providing a benefit; there’s nothing to compare to previous scans unless there is recurrence.

Also, as I just related in another post, Dr. West has often said that treatment of stage IV lung cancer should be a marathon, not a sprint. So we seek to get the most benefit from each therapy used. In your mother’s case, that objective would best be met by not using a therapy until it is needed.

I don’t think there’s good evidence that delaying the use of Tarceva improves survival by delaying the onset of resistance.

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

March 4, 2016 at 7:45 pm  #1273144    

sidekick4mom

Thanks Jim for your reply. I’m asking because her oncologist is quite strange. He doesn’t like to make choices. Every step of the way, he tells us what our options are and let’s her choose, which is not very helpful at all. He simply won’t give an opinion either way.

In any case, if the more prudent course of action is to not start on Tarceva, what’s the best approach going forward? Should she get scanned periodically, like say every three months? What’s a good safe interval to monitor for any signs of recurrence? I want to be sure that if there is recurrence, its caught as early as possible.

Also what good tests besides PET scans are available to monitor for signs of recurrence?

March 5, 2016 at 5:43 am  #1273147    
JimC Forum Moderator
JimC Forum Moderator

A three to six month scan interval is pretty standard, although there is plenty of variation among oncologist. Often the interval is lengthened after a period of perhaps two years or so. Dr. West has this about follow up scans:

“As far as following progress with a CT vs PET, there is a GRACE FAQ on this subject here: http://cancergrace.org/cancer-101/2010/09/16/cancer-101-faq-assessment-response-of-cancer-to-treatment/

The conclusion is “Some people favor getting PET/CTs to clarify response in extreme detail, but there is a real risk of identifying clinically insignificant changes, such as by a minimal increase in the PET uptake of a tumor that remains stable in size, that might lead to a change in management that isn’t clearly necessary…Individual physicians have different perspectives about their reliance on PET scans and serum tumor markers in monitoring the course of a cancer, but for most solid tumors (cancers of solid organs where there is visible evidence of the cancer), changes in the size of known cancer on serial CT scans at regular intervals of follow-up remain the best studied and most validated way to assess response to treatment or monitor for progression off of treatment.”

And Dr. West has also said:

“There are certainly some very thoughtful oncologists who regularly obtain serial PET/CT scans to assess response vs. progression, and I don’t think that a financial motivation is the only or even a leading reason for this pattern. I think it’s primarily a thought that the newest technology must be the best choice. However, I sincerely question that the incremental helpful information of a PET/CT over a CT is greater than the incremental unhelpful information it provides. Specifically, I just fall back to the premise that the vast majority of the time, any clinically significant progression is going to be detectable by a combination of standard CT scans and any symptom-directed imaging.”

[continued in the following post]


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

March 5, 2016 at 5:46 am  #1273148    
JimC Forum Moderator
JimC Forum Moderator

[continued from previous post]

“In contrast, I think that the PET/CT, like extreme focus on serum tumor markers, facilitates detection of incredibly minimal, clinically insignificant progression that may lead us to make poor decisions, such as discarding a well-tolerated treatment on which a person has cancer that isn’t growing in size. I am completely unenthusiastic about stopping a well tolerated treatment just because a stable lesion has had a rise in SUV on a PET from 5 to 6, or because the serum CEA level has risen by 10%. I think of this as just jumping from lane to lane in bad traffic. It doesn’t help you get any further any faster: you’re just anxiously moving around more. And I think it may well be a real mistake to have a slight SUV rise lead you to discard a well tolerated treatment far earlier than really necessary.

“So in the end, I’ll say that I could nearly as easily get PET/CTs for regular response assessment of my own patients, but I don’t because I don’t think it leads to better clinical decisions, just more expense and potentially more anxiety that can lead to worse management decisions.”http://cancergrace.org/forums/index.php/topic,8226.msg61816.html#msg61816

Finally, there is no evidence that catching a recurrence a few months earlier improves outcomes, so although it’s difficult to do so, please try not to stress too much about seeing any recurrence the moment it occurs (hopefully, not at all!)

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

March 5, 2016 at 10:35 pm  #1273152    

DJ Nikkam

Hi – great explanation by Jim…

My mother, aged 66 (of asian origin as well) is also diagnosed with Stage IV adenocarcinoma. She started her for line Chemo of Pemetrexed / Carbo on Feb 25, 2016 (first cycle). So far she seems to have responded well, with her most obvious symptoms cough, chest congestion, fatigue and breathlessness having subsided, to a point where her quality of life has improved. She continues to have fluid (pleural effusion) in her left lung (around 460ml). She has tested positive for ALK D5F3 analysis, while negative for EGFR mutation. Her doctor is thinking that we he complete atleast 4-cycles of Chemo, and subsequently think of switching her to oral meds. Though I am not sure what oral meds he would consider for ALK positive mutation

I am seeking to get more information on the number of Chemo cycles that your mother went through, and if she was also on the same combination of meds. What was the follow up post the first set of Chemo to determine she did not have any active nodules / lesions (was it a PET Scan?)…

thanks for your response
DJ

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