why can't we go back?

This topic contains 6 replies, has 4 voices, and was last updated by Dr West Dr West 2 years, 10 months ago.

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January 10, 2015 at 9:33 am  #1267991    

drgoogle

My husband, NSCLC, Stage IV, had v.g. results on carbo/vinorelbien and had no treatment after initial chemo for approximately 8 months. Put on pemetrexed in September. November suspicious nodule, a wait and see strategy adopted. January scan showed growth (now at 1 cm). Pemetrexed scheduled next week cancelled and oncologist suggests Tarceva as next option to begin within 7 days.

Please help us understand why husband can’t go back to first chemo that he did so well on. Is it a question of toxicity or other? Thanking you in advance….

January 10, 2015 at 10:18 am  #1267993    
JimC Forum Moderator
JimC Forum Moderator

Hi drgoogle,

The main issue is repeating treatment with the platinum agent, in this case carboplatin. Such drugs are tough on bone marrow function, and in general their use is confined to first-line use, although as is typical with cancer treatment exceptions may be made.

There is a discussion of this issue here. In that thread Dr. Weiss describes his thinking:

In the 1st line, I treat to 4-6 cycles, then will always drop the platinum (I leave the question of maintenance and switch-maintenance without platinum to another day). In select patients whose cancers seem particularly platinum sensitive, I will sometimes “break the rules” and bring the platinum back in a later line of therapy; this is a common practice that many oncologists consider for select patients. The second caveat is that a small minority of oncologists consider this to be a controversial area. One very prominent oncologist in New York makes very reasonable arguments based on meta-analyses that there may be benefit to more than 4 cycles of platinum, perhaps even treating to progression. In my opinion, any small survival difference that may be accrued is not worth it (think Ned’s BEVSEV) in terms of side-effects, except perhaps for the very most platinum-sensitive patients who tolerate platinum extremely well.” – http://cancergrace.org/forums/index.php?topic=7276.msg52702#msg52702

At times oncologists return to a first-line agent (in this case vinorelbine) if there was a good response initially that was long-lasting, and that’s not clear in your husband’s case. On the other hand, the three FDA-approved drugs for second and later line therapy are Pemetrexed (Alimta), Erlotinib (Tarceva) and Docetaxel (Taxotere), so it’s not surprising that your husband’s doctor would recommend one of them. Since he’s already tried one of the chemo agents (Pemetrexed), he’s chosen the non-chemo agent Tarceva.

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

January 10, 2015 at 2:05 pm  #1267995    

drgoogle

Thank you. One more question. Is Tarceva successful for treating those who may not be EGFR? My husband has not been tested as this testing doesn’t seem to be the ‘norm’ here.

January 10, 2015 at 3:03 pm  #1267997    
JimC Forum Moderator
JimC Forum Moderator

In first line treatment, Tarceva is really only appropriate for patients with activating EGFR mutations, as patients without such mutations do better with standard chemotherapy agents. But Tarceva can provide a benefit to such patients in second and later lines of treatment, as described in this GRACE FAQ: http://cancergrace.org/lung/2010/09/21/benefit-from-egfr-tki-if-egfr-wt/

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

January 10, 2015 at 3:10 pm  #1267998    
catdander forum moderator
catdander forum moderator

Trial data show that tarceva can be effective in people without the EGFR mutation call wild type to maintain stability almost as well as some chemo drugs. This is why it’s FDA approved for 2 line treatment (that’s 2 and beyond lines to us, there are no “approved” lines beyond 2nd but of course we use them when possible.) Below is a video blog on the subject followed by a list of links on the subject. It’s well used and discussed.

http://cancergrace.org/lung/2012/08/27/socinski-tailor-trial/

http://cancergrace.org/lung/tag/egfr-wild-type/

Who knows maybe your husband has the mutation and will do well for a long long time.

Hoping for the best,
Janine

January 10, 2015 at 4:22 pm  #1268001    

drgoogle

Many, many thanks. I knew if I did not pose my questions today, I would endure another sleepless night when all my questions, fears seem to flood my mind. This happens most often after we have been to Oncologist and I walk out of there and wonder why I didn’t ask this, that or the other and then find myself regurgitating the conversation trying to make sense of what we heard and trying deperately to make sense of next steps. Again, thanks for being there. I hope you know what a difference you make in people’s lives.

January 10, 2015 at 5:25 pm  #1268004    
Dr West
Dr West

Jim and Janine have provided all of the relevant information here, so I’ll just welcome you and say that if you have additional questions, I and other people here will be happy to try to help.

Good luck.

-Dr. West

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