Initial Diagnosis: NSCLC andenocarcinoma
My 65 year-old wife, diagnosed with Stage II, had right lower and middle lobes removed 16 months ago. Margins clean and no sign in lymph nodes. Followed by Cisplatin & Pemetrexed 4x. Six months ago CT showed small nodules (under 1cm) in left lung. Next CT (3 months ago) showed more nodules and marginal size increase (still under 1 cm) in a few. She opted for a bronchosopy (17 sections) which yielded no result, probably missing nodules. Latest CT (2 weeks ago) shows 'no significant change in size, however, there is increased modularity inferiorly within the lingual.' Given the size of nodules we are told only surgical biopsy will yield certain result - otherwise continue periodic CT scans or needle biopsy if/when nodules are large enough.
If this is cancer, is there anything to be gained with an earlier diagnosis via surgical biopsy? Although at first very anxious about nodules, my wife is now happy to wait it out with the periodic CT's - as long as there's no discernible advantage (as we've been told) to starting treatment earlier - if indeed this is cancer.
Reply # - February 28, 2013, 09:24 AM
Reply To: Benefit of Surgical Biopsy on Nodules Under 1 cm?
She's absolutely right. There's no need to poke around for trouble if it's cancer there's no need to start treatment sooner if there aren't any symptomatic problems. If it's not cancer, which is what we're hoping for, the procedures are invasive and have a chance for complications. Surgery is a major invasive procedure, hopefully the surgeon wouldn't even want to do it.
It's a really good sign the nodules are stable. Let's hope they stay that way or better yet they disappear.
There is an algorithm in this post about less being more. The topic cancer is BAC type adeno nsclc but holds true for other slow growing cancers. The main point being less is more, http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/
Reply # - February 28, 2013, 01:34 PM
Reply To: Benefit of Surgical Biopsy on Nodules Under 1 cm?
While the link above does state the idea that the algorithm applies to other slow growing cancers the below link is the one I had in mind. I didn't realize they were 2 different pieces...sympathetic memory issues don't ya know.
Also read the comments. Dr. West's first one also addresses the subject.
http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/
Dr. Weiss is even pitching a research idea along the same lines of less, http://cancergrace.org/topic/any-studies-on-changing-chemo
Reply # - February 28, 2013, 10:19 PM
Reply To: Benefit of Surgical Biopsy on Nodules Under 1 cm?
These all explain the general mindset that if things are changing so slowly that you can barely perceive any change over interval scans, there probably isn't clinically significant progression of disease. It's also true that if there is multifocal recurrence after surgery, there is no great incentive to rush in to treat it long before it's symptomatic and barely able to be diagnosed without great effort. You only know about it very early, but there's no missed window of opportunity.
If anything, I find that the follow-up scans provide valuable information about the underlying pace of the disease, which is an extremely useful piece of information to have when trying to make thoughtful decisions about the optimal treatment approach for someone's cancer -- if very slowly growing, the treatment may very well be worse than the disease.
-Dr. West
Reply # - March 3, 2013, 06:54 AM
Reply To: Benefit of Surgical Biopsy on Nodules Under 1 cm?
The purpose of treating cancer is to live longer and to live with higher quality of life. When possible cancer progresses slowly, it does not create a threat to quality of life or duration of life. When this level of threat from the cancer is low, there are situations where the risk/benefit balance to an intervention (such as biopsy, surgery, chemo, etc. depending on the situation) actually exceeds the risk of the cancer. In these cases, the "better" path can often be careful observation. The key words in the last sentence are "careful observation" which is not equivalent to doing nothing. The fear in observation is that the cancer will accelerate its growth. This fear can be minimized by both doctor and patient. The doctor can scan frequently to keep an eye on the cancer (the definition of "frequently" of course, varies by situation). The patient can reports immediately to the doctor any changes in symptoms or new symptoms that should prompt even sooner evaluation that might indicate a need for a chance in strategy.
Reply # - July 9, 2013, 09:51 AM
Reply To: Benefit of Surgical Biopsy on Nodules Under 1 cm?
Thank you Dr(s) West and Weiss and Catdender for your responses.
I described my wife's initial condition at top of this thread in regards to nodules in left lung.
Her latest scan was in early June and it showed more nodules than last scan (late Feb) with discernable growth in several, but none larger than 5-7mm. The right lung (lower and middle lobes removed) is clean. She underwent needle biopsy last week and it confirms NSCLC andenocarcinoma. She has a cough (she also has GERDS) and perhaps some mild fatigue, but is otherwise healthy.
Our Oncologist suggests 2 treatments of Pemetrexed and Carboplatin 3 weeks apart followed by a scan to see if there's any shrinkage. She did well with adjuvant treatment of Cisplatin & Pemetrexed with relatively mild side effects. We are told there is no rush and the treatment will be equally effective if we decide to wait. Her quality of life is relatively unimpaired.
Are there any stats on longevity based on when chemo is started? It's hard to believe there's no benefit to starting right away, but then perhaps because chemo only works for so long it's best to put it off in the hope of extending effectiveness of treatment?
I'm also wondering if there is a short-hand description of her present condition to help me search the site - is she still considered Stage IIb, is this 'locally advanced NSCLC', or 'Advanced NSCLC', or is there some other description?
Reply # - July 9, 2013, 09:30 PM
Reply To: Benefit of Surgical Biopsy on Nodules Under 1 cm?
She has recurrent NSCLC, and the best description is "advanced NSCLC" now, or really "indolent advanced NSCLC".
In terms of the timing of chemo, the little work that has actually been done indicates that overall it's beneficial to start chemo earlier rather than later, but that really ignores the reality that some people have very indolent cancer and others have much more aggressive cancer. It's really a mistake to lump all advanced NSCLC together as if their biologies are all the same. I think it's completely appropriate for people with indolent NSCLC to delay therapy, likely preferable, and I know that many other lung cancer specialists favor this approach as well. Please read here:
http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/
Good luck.
-Dr. West