How soon should chemo be started after a lobectomy - 1252624

hopegrows
Posts:3

My mother just had her LLL removed due to a 7 cm adenocarcinoma mass that had cavitated from her avastin treatments. She also had a wedge resection done on her ULL for an 8 mm BAC lesion. She has multiple GGO's throughout all lobes, but none are as large as the 8mm one that was removed. She has had carboplatin, texotere, and avastin for 6 months, prior to her surgery. The surgeon said he could not biopsy any of the other GGO's during surgery because they were too small for there to be anything to send to pathology. He said, " I got what I could feel,". So... Now we have a follow up appointment with her surgeon in 2 weeks and her oncologist. We are wondering what should be done now, more of the same chemo? Or a maintenance chemo, or a watch and see approach. Her oncologist tends to steer towards chemo, chemo, chemo... But we don't want her quality of life to be affected anymore if we don't have to.

5 years ago, ct showed 2 cm nodule in LLL, and GGO's throughout both lungs.
6 months ago 7 cm mass, adenocarcinoma by biopsy, in her LLL bad an increase in the GGO's.
1 week ago LLL removed and LUL wedge resection
Chemo of carbo, texotere, and avastin. Carbo and texotere once a week for the last six month, avastin once every 3 weeks for the past 6 months. She's had no chemo since December 5th in preparation of her surgery.

Also, her last CT showed a small pleural effusion.

She is doing really well 8 days out of surgery. The only complication she had was an hour of AFib with RVR or 155 that she converted on her own. Yesterday we walked 1.25 miles.

Any answers would be greatly appreciated.

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Reply # - January 15, 2013, 03:39 PM

catdander
Posts:

Hi hopegrows, It's good to hear your mom is walking over a mile. It sounds like a good sign.
With stage 4 nsclc chemo is the standard of care. When, how much, how often, and how much of an effect you can expect to have all depends on the individual. However there is usually a wait of at least 4 weeks after surgery to let the body heal.

I wonder if they expect the rest of the tumors or ggo's will continue to be indolent.

Anyway, I'm not a medical professional just a wife and moderator. There is much written on invasive BAC and adeno and nsclc in general. A search on our search engine usually generates a lot of useful info though you may need to log off before using it.

I'll contact a doctor to comment on your questions though no one will be able to say what is best for your mom without being their patient.
You should hear back within a day.

All best,
Janine
forum moderator

Reply # - January 15, 2013, 08:12 PM

drevans
Posts: 6

Congratulations on her being up and around!

So chemotherapy is the standard for stage IV lung cancer, or lung cancer that has spread from the lung where it started to distant sites. However, would not do more than 6 cycles of carboplatin as does not seem to add additional benefit. In addition, Taxotere has cumulative toxicities, so usually patients cannot tolerate more than 6 cycles. Maintenance Avastin would make sense in the setting of metastatic disease that has not gotten worse on the initial chemo, usually waiting 8 to 12 weeks post surgery.

One thing I wonder, however, is this truly metastatic disease? You mention a pleural effusion. If the pleural effusion has cancer cells in it, then this is metastatic disease, and a maintenance chemotherapy approach is reasonable (with Avastin and pemetrexed being reasonable maintenance choices), but only if it does not severely compromise quality of life. However, it could be that the main 7 cm tumor had not yet spread and now has been completely removed by surgery, and the other GGO's (ground glass opacities) are other areas of BAC's (bronchioloalveolar carcinomas) that are NOT related to the primary tumor, but arose independently (multifocal disease). Some lungs just seem to form BAC's. These can be VERY slow growing tumors that do not necessarily require treatment if they are not growing quickly, though they do need to be followed with imaging studies to make sure they do not "go bad" and take on a more aggressive form, which may have been what led to the development of the 7 cm tumor. While the 7 cm tumor is relatively high risk for future metastases given the size (but the lack of lymph node involvment is a good sign!), the only thing that would usually be recommended to reduce the risk of recurrence/metastasis would be 4 cycles of platinum-based chemo, and she has already received that, so no more chemotherapy would be required until and unless it appeared the cancer were getting worse.

Reply # - January 15, 2013, 09:22 PM

Dr West
Posts: 4735

I agree with Dr. Evans about the potential for some lung cancer nodules to be so slowly growing that they don't require any ongoing treatment, and continuing on chemo month after month, year after year is likely to provide no benefit but just wear down a person.

I'm writing a chapter right now on multifocal BAC, and a main theme of it is DON'T OVERTREAT PEOPLE WITH SLOW-GROWING CANCERS. The oncology community does that a lot -- surgery, chemotherapy, and/or radiation for people who would do as well or better without it, or with a lot less, given much more judiciously. I would say that the key is to carefully assess what's actually growing and how fast.

I'll do a post about this in the next few days. The more I read and write and think about these situations, reviewing the literature of what people do and congratulate themselves for, the more concerned I am that to many cancer docs (surgeons, med oncs, radiation oncologists) are just taking credit for how well a person would do anyway because their cancer just happens to be slow-growing, and they're still doing well despite (not because of) the aggressive treatments they're receiving. (NOTE: this only applies to cancer that is actually shown to be very slowly progressing, not the kind that lights up a lot on PET scans or grows readily from one scan to the next.)

-Dr. West

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