Is surgery an option in stage IV NSCLC? - 1251486

Hello panas, I'm so sorry your mother is in this position. I'm not aware of any new information suggesting malignant pleural effusions are curable. I'm not a doctor so of course don't want to suggest my knowledge is the last word of today's understanding of lung cancer.

The latest in on the subject on Grace is here, http://cancergrace.org/radiation/2012/11/24/sbrt-for-oligometastatic-lc/

Here's a link to the discussion on the subject of oligo metastatic nsclc. Scroll down to the section titled oligometastatic disease, http://cancergrace.org/lung/2011/07/07/world-lung-conference-day-4-7720…

Also Dr. Weiss has written this on the subject, http://cancergrace.org/forums/index.php?topic=9855.0

I hope this gives you a better understanding for follow up questions.
All best,
Janine
forum moderator

We've had similar discussions in our tumor boards, but other series have shown less favorable results. Our surgeons, who had been receptive to the concept and are usually quite eager to surgery any time it's appropriate (and sometimes even when it isn't), have reviewed the range of these kinds of reports and don't do this surgery.

It's worth bearing in mind that these small series are also subject to a lot of selection bias, as well as publication bias. Selection bias means that patients who pursue an unusually aggressive treatment approach that is beyond the typical standard of care aren't the same as the general population: they may be unusually young, fit, aggressive-minded, have unusually little disease, or other factors that not only make them candidates for a different approach but also make them likely to do better than the general population no matter what they do. Publication bias refers to the tendency for positive results to be reported and published, while negative results are ignored, never written up as potential publications, and if submitted for consideration may not be accepted. So a single positive report may not be an accurate picture of reality if there are in fact 5 or 10 other series that actually showed little or no benefit, but they remain unwritten or unpublished.

There is always room for good clinical judgment and often an individualized approach for a particular case, but the clear, prevailing standard around the world for someone with a malignant pleural effusion and/or pleural nodules is systemic therapy with no role for surgery.

-Dr. West

Thank you panas for this interesting question. I hope there will be more discussion of this subject when the webinar with the surgeon Dr Harpole is put online.
To me, as a stage IV patient, a five-year survival rate of 26.8 per cent doesn't seem that great. I'd also like to know how the patients fared who didn't make it that far.
I am currently having more problems with measures that were taken to palliate the disease (a stent) than with the disease itself. Very occasionally I wonder if it would be worth having my bad lung taken out - assuming the surgeon and the hospital where I am treated would be prepared to do it, which is a big assumption. I know the risks of surgery are high, and I have an inkling of how painful and tiring it is afterwards. I suspect my quality of life on Tarceva is much better than a post-thoracotomy existence would be, Then I think of how I would feel if, after all that pain and trouble, I developed liver mets or similar a few months later.
I hope your mother does very well on Tarceva.

Tarceva has shown efficacy in bone metastases especially for those who have an EGFR mutation. However tarceva is FDA approved for second line treatment for all who have nsclc, that includes mets to bone also.

Tarceva isn't the first choice for brain mets but there seems to be some activity in some people however the treatment that has shown to have the best efficacy is either wbr or stereotactic brain radiation (for 1 to 3 or so mets).

Here is a new short video that's very informative. http://cancergrace.org/lung/2012/12/06/get-the-lead-runner-local-rx-for…

I discussed this issue with a good friend who is also a terrific thoracic surgeon colleague of mine, and he reiterated that other groups of surgeons at great centers like Brigham and Women's Hospital have tried this and found disappointing results, leading them to not want to continue the practice. My friend had also recently done a surgery in an unusual case of someone doing extremely well, with just a single area of visible disease on a long course of systemic therapy, only to have this patient develop liver and other metastases just a few months after the surgery. He's certainly interested in reviewing this new paper, but you're absolutely correct that the biology of a cancer spread to the pleural lining and with a malignant pleural effusion is consistent with a systemic process of microscopic cancer cells being able to travel within the bloodstream to other distant sites...and that's the key problem.

[i]certain spring[/i]: I'd say that "palliative lung surgery" is a phrase we rarely utter, but there are rare patients in whom it might be a consideration. Most often, it's a great deal to go through and recover from, which is not typically offset by the anticipated duration of benefit from the intervention...but that's not to say it would never be an option.

-Dr. West

I know you've asked Dr. West but I think I can help your understanding.

It isn't feasible to go through a procedure like a thoracotomy if it isn't going to cure you. Because it isn't likely to help you live longing and better. At this time most people with stage 4 nsclc will not benefit from surgery and it's not yet understood who might.
It happened to the patient Dr. West speaks about and unfortunately it happens to people all the time who appear to be earlier stage but have micro-metastases. They have the very difficult surgery and while they are recuperating the cancer progresses because they aren't getting the type of treatment they really need. They are too sick from the surgery and have to wait for systemic treatment. Sometimes it's too late for treatment by the time the person recoups.

My husband had a similar situation in that he had an open thoracotomy while chemo was the best first treatment. No one was able to get cells through any other biopsy method so to get that blame cancer under the microscope/diagonsis they had to operate. He was in relatively good condition going in and was able to undertake systemic treatment 4 week after surgery. I honestly am overwhelmed by thinking about it now because I didn't think he was going to make it at the time. 3 and half years later he still has quite a bit of discomfort from the surgery but he as able to withstand chemo and improve.

For many they never improve enough to have the treatment they need.

Is that what you were asking about?
Janine

So good to know she is feeling well. I hope she well with tarceva for a long time.

I don't have those details (this isn't a patient of mine, and I was only told about her in passing), but I would say that if someone is being kept from demonstrating more widespread metastatic disease only because the spread is being suppressed by active systemic therapy, local therapy wouldn't have any rationale or anticipated value.

-Dr. West

In reading this thread, I am a little bit confused. Why would my doctors have chosen to resect my brain tumor instead of just radiating it? It was clear at the time that it was a met from either my breast or my lung (they assumed breast since it was newest cancer). However, if they had chosen not to resect, the treatment wouldve been the same regardless of the origin, isnt that correct?

Very fair question, and no clear right answer. It wouldn't have been wrong to go straight to radiation, but surgery for a solitary brain lesion is still a consideration -- sometimes to immediately improve symptoms, sometimes to clarify the diagnosis (especially if there are at least two potential cancers that could metatasize to brain). Obviously, you can't define the diagnosis by just radiating the lesion.

It's true that the immediate treatment would likely be the same either way, but I think a very good argument can be made that there is a value in knowing with certainty what the diagnosis is, and it could certainly have implications if there's subsequent progression elsewhere.

-Dr. West

Dr. West,

Pardon me if I sound like I have been watching too much NOVA and other science channels, but I have a technology question. After watching Dr. Mehta's podcast again from Nov. 27, 2012, I began to wonder about how SBRT may become more sophisiticated and effective with improving technology. Reading about advances in space, military as well as other medical technologies, I realize that further sophistication of our tools is bringing capabilities to those arenas that have never been seen before. Further, improvement with SBRT may allow an even more aggressive approach to oligometastatic disease. Possibly, the number of treatable lesions with such a tool may increase. The other aspect of this that I wonder about involves potential tumor progression when other therapies are on hold when radiation or surgery is implemented. Will there be any way to improve on this?

To go with this, if we come up with more effective combination strategies that are more effective at slowing cancer mets in advanced cancer cases, the SBRT could be a tool to allow the existing treatment strategies some staying power - just as been suggested with in the case of EGFR inhibitors. Better carpet bombing strategy of treatments combined with sophisiticated SBRT could truly prolong patients' lives! I hope that I don't sound like sci-fi guy and I hope that I am making sense, but when you are hear about treatments which are legitimate and sound like there is room from improvement. Any thoughts would be greatly appreciated.

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51 year old male
Diagnosed with stage IV lung adenocarcinoma in February 2012
Successful treatment with Tarceva
Looking forward to reports from ASCO 2013

Hi Dave, you don't sound far out to me. I don't know where the technology stands on this today. But know that's mainly because I don't have the need to know today. My husband is very lucky and is NED 6 months off treatment. Because his cancer is unique in that it has responded so well or whatever happened to make him NED be sure I'll be checking out this and many other possibilities when/if the time comes.

I'll make sure Dr. West or Dr. Weiss comments.

All best,
Janine
forum moderator

I think the issue with most metastatic disease is that there are simply too many areas to try to stay on top of with focal radiation to every single spot: because the cancer cells circulate in the bloodstream, you just can't stay ahead of the tide of new disease by focusing on every single visible spot. Moreover, the radiation still needs to have a rim of treated tissue around it, because we can't be completely sure where the cancer vs. normal tissue is, and this means that there is some collateral damage to surrounding tissue. If you were to do that all over, it would have some pretty significant risks associated with it.

The other issue is that cost of treatment is likely to be a growing issue, and doing focal radiation to 40 sites means that the charges will be 40x what they are now. The reality is that there isn't a health care system that can afford to spend 2 million dollars per person on the treatment of everyone's metastatic cancer, particularly if it still isn't going to be curative (proven to be so, rather than a speculation that it might be helpful). And while I'm sure that there are people who feel that society should pay an infinite amount of money to treat cancer, we don't live in a world of infinite resources, and there still needs to be a place to pay for roads and schools and other things that keep societies functioning.

Overall, I think that before we envision a world of infinite possibilities of what medicine will deliver, we need to acknowledge the reality that there is no society that can manage to sustain itself while directing the majority of its resources on health care, particularly in a setting in which the results aren't established to be curative.

-Dr. West

I respectfully have a different perspective. From a scientific point of view, I think that radiation may indeed be underexploited in the treatment of stage IV disease.

One possible role is to avoid complications with central tumors. Larry Marks, a radiation oncologist at my institution, recently published UNC's experience w/244 consecutive patients enrolled in phase II/III 1st line trials. Patients with bulky hilar disease (those nodes in the center of the chest near the major airways) and pneumoniae at diagnosis had a very high risk of needing radiation later. In my practice, after 4 cycles of chemo, I do consider XRT for such patients to provide later local problems.

What about the question that texandave actually asked, about improvements in SRS leading to a bigger role in treatment of stage IV disease? For most patients, I agree with Dr. West that because SRS doesn't address micrometastatic disease, it would be like playing "whack a mole" at the arcade--the spots that you don't hit pop up to cause problems. However, in some patients, progression of these spots can be very, very slow. I regularly use observation for many months in my slowest progressing patients. Could some SRS allow them to go longer without chemo? In my opinion, the greatest limitation to additional use of SRS is inadequate imaging. Could better resolution scans and scans with novel PET tracers allow us to detect smaller spots that could be treated with SRS? From a scientific/technical standpoint I think that for small cancers, SRS is pretty good at targeting a tiny spot right now. The technology that I most thirst for to make it better is better imaging to decide what to hit. Dr. West also brings up money. Here, he is undeniably correct right now. If we were to do SRS to many spots on every stage IV patients, we would certainly break the bank right now. But, most technology gets cheaper over time. Over time, I expect that the cumbersome long treatment planning (to be cont)

(cont, with apologies for blatantly ignoring 2000 character limit)

will be aided by computer and therefore become easier and cheaper. Most tech is very expensive when new, then cheaper over time. Perhaps the same will happen with SRS.

So, the bottom line is that for now, SRS does not have a major role to play in the treatment of stage IV disease. Even in EGFR mutants, that role is experimental, not proven. However, it is my opinion that with improving technology, it MAY play a much greater role one day in the future.

I think there's room for different opinions here, but with so many things in life and medicines, it's really a matter of degree. For a few lesions outside of the brain, a reasonable argument could be made, and I think that some patients may potentially benefit.

The biggest problem I see is that we don't tend to bring the right judgment, so if we say that it might make sense to use SRS judiciously for appropriately selected patients, what you end up seeing is a much broader population with too many lesions, truly not strong candidates for this kind of approach, being shoehorned into a slippery slope that highlights the differences between what we can do and what we should do.

Money is an issue and a realistic barrier to being too haphazard in our approach to this question, in both directions. I completely agree that costs will come down for technologies that are expensive now, but I also recognize the current reality that some of the temptation for over-use of these technologies is because they are financially remunerated. If institutions were being paid per patient and not per intervention, I suspect we couldn't believe how quickly the trend toward more treatment would change.

As prices decline for current technologies, there will also be new technologies with exceptionally high price tags that will be favored just because they're newer and need to be paid for. My personal view of proton beam radiation therapy, which is shared by many prominent leaders in radiation oncology, is that it is driven far, far more by marketing and financial motivations than by any evidence it improves outcomes. There is actually no evidence that proton beam radiation therapy improves outcomes in cancer patients at all outside of very rare conditions, yet it is a runaway train that has an engine of private venture capital interest, independent of any medical interest, behind it in many parts of the US.

-Dr. West

I absolutely love the kind of conversation and is one of the very first reasons I'm glad to have Dr. Weiss taking a more active rule on Grace once again.

We need to see more perspectives so we don't forget there's rarely one right answer or one angle from which to view a question about cancer and healthcare in general.

Thank you both.

Absolutely. Importantly, we both appreciate the view of the other, and we don't exhaust the perspectives out there. I think it's incredibly valuable that there are other opinions here than mine and that Dr. Weiss will speak up to challenge my views.

I should say that I'm sure my views have been influenced by his and those of other people I respect here. I think that one of the reasons I became more receptive to Abraxane is based on his being impressed with the data and his own experience with it. I have similarly been impressed, both looking at the data that he highlighted and by my own experience I gained.

That's just one example. I think it's really important for all of us to be challenged by other views and be able to defend why we still favor our own interpretation or revise it based on a new perspective. I don't want to ever be so fixed in my views that I can't revise them based on new information and/or a thoughtful new interpretation.

-Dr. West