Multifocal BAC, When is there treatable progression? - 1254688

hobbes
Posts:12

My husband (59 yr old, non-smoker in excellent health) was initially diagnosed on 11/08 with Stage1 BAC (one small nodule) and had a lobectomy. After 18 months a cluster of very small (6mm and less) nodules appeared on his other lung, but the results were inconclusive. His next scan in 11/10 showed ~2mm of growth in a few of the lesions. He had a biopsy done which was pos for BAC, then went to MDA where he tested positive for EGFR and started taking Tarceva on 12/10 with good results. Over the next several months, all but three of the nodules disappeared and the remaining 3 shrunk/ looked hazier/ less solid. There was no change in scans until 3/13 when the 2 larger nodules "increased slightly in size and solid appearance" since his September scan.
His doc at MDA suggested that he stop taking the tarceva at the end of this month and he is going back to be evaluated for surgery v cyberknife v just go back to taking the tarceva. He is in excellent health and asymptomatic and there have been no new sites of ground glass and no new nodules since 4/09 to date. It appears that the 3 remaining "part solid nodules"- the largest of which is 1.2 cm- are in the right mid lung and they would be removing all 3.
I've read all of the excellent information you've posted about knowing when to treat and more importantly when not to treat and I know there's no perfect answer/formula. Our dilemma is that it seems possible that the lesions that were seen on the 5/10 scan were there when the original d/x was made in 11/08 (those scans were done locally and the resolution was not as good as those at MDA) so maybe there really hasn't been any recurrence; is it multifocal? Does that matter with respect to treatment? His onc told us that he is treating this as though it were Stage 1. Since the lesions have just started to become more dense/solid and grow, does this seem like they are clearly progressing; is this the right time to remove them?
Thanks so much for all of your help.

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Reply # - March 12, 2013, 10:20 PM

Dr West
Posts: 4735

Hobbes,

I'm truly sorry that it's not possible to provide any meaningful commentary here, but as you can probably well imagine, your husband's situation is one in which there's no way to offer any insight without being completely involved. I just can't surmise what's happening here from your summary, and that's not your fault. This is too complex a case to make an intelligent comment based on a brief summary over the internet.

I think it's most helpful here to find someone whose judgment you can trust, or if you have doubts, seek a second opinion before making any irreversible decisions.

-Dr. West

Reply # - March 13, 2013, 03:52 AM

hobbes
Posts: 12

Thanks Dr West. I just wasn't sure how critical BAC staging is in terms of how much, if any, impact it has on treatment particularly since the change to the newer classifications of AIS etc. We truly do have a very high level of trust/confidence in his docs at MDA, they have been wonderful and we've been very lucky that his BAC has been indolent and/or that the tarceva has been effective, that there haven't been any new nodules show up on the scans since 2010, and that he is likely to have both resection and radiation as options. Although we're hoping that whatever we choose will leave him without any remaining BAC, I know that there is always a good probability of recurrence with this disease. Since it's been so indolent this time, is it likely that any recurrence might also be as indolent?

Reply # - March 13, 2013, 08:57 AM

catdander
Posts:

Hi hobbes,
It's very possible that a recurrence of an indolent BAC or any indolent nsclc will also be indolent. As with everything else about cancer anything can happen though.

BAC is treated, by stage, in the same manner as any nsclc, in this case there is added the caveat of an indolent lung cancer. I understand the bit of extra hope you have for your husband, mine too has a very indolent nsclc and I've asked these same questions. There is hope in that if we play our cards right we can make this game last a good long time, treated maybe even as a chronic illness.
This is a recent discussion about treatment of indolent lung cancer specifically BAC. Don't miss the further reading at the end of the discussion. http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

All best,
Janine
forum moderator

Reply # - March 13, 2013, 04:12 PM

Dr West
Posts: 4735

Yes, just to confirm that it's absolutely fair to presume that if a cancer has been indolent when followed in the past, it's also likely to be indolent if it recurs. Of course, cancer can do anything, but the leading expectation would be that the biology and pace of disease would continue to follow the same trajectory as was seen previously.

Good luck.

-Dr. West

Reply # - March 14, 2013, 07:18 AM

hobbes
Posts: 12

Thanks so much Dr West and Janine. There are so many things to consider whenever there are options around treatment and so far, he has been doing very well. I did read a recent post that was in response to a patient who said that his father had surgery which removed his BAC and asking about chemo as a adjuvant treatment. In our case, would it make sense/be a consideration for my husband to resume Tarceva if he has surgery or radiation to remove his lesions and was, theoretically at that point NED? I known that his lesions have started to grow slightly while he's been on tarceva, but is there also a possibility that maybe the Tarceva was still being effective in some way, since he has also not gotten any new spots since then? Thanks again for all of your help.

Reply # - March 14, 2013, 08:01 AM

hobbes
Posts: 12

Hi, I might have posted too soon; I just read your response, Dr West as well as Dr Weiss' to the question of whether to do chemo as adjuvant therapy when there is no cancer last after surgery. Would the answer be the same with respect to not using targeted therapy -in this case- Tarceva, if the procedure were done with a cyberknife or similar type of radiation, since it seems that there is a period following the procedure before you know if it was successful? And, in general, is there a chance that the Tarceva my husband was taking might still be considered as an effective treatment for him in the future since there were no new growths during the 2 years he was taking it? Thanks again.

Reply # - March 14, 2013, 11:58 AM

catdander
Posts:

hobbes, I know you and your husband and the doctors will come to a decision that will be right for him. But I know too that the process is mind boggling, especially when you're in such an individualized circumstance. I can imagine me being in a similar place some day too. I know it's better now than having an aggressive cancer but I don't know that it's any easier in the long run.

I don't know that our doctors will be able to give any specific insight but I'll make sure Dr. West comments by today's end.

I assume you've read the link from my previous post and more but am pointing it out again just in case.

All best,
Janine

Reply # - March 14, 2013, 04:42 PM

Dr West
Posts: 4735

I would have no enthusiasm at all for adjuvant Tarceva in someone who has undergone surgery and has no evidence of disease. Though the evidence for adjuvant chemo in this setting is weak, it's stronger than the evidence for a targeted therapy.

The question of whether there would be a value in returning to Tarceva in the event of recurrence really depends on whether there was progression on it previously. If there was clear, multifocal progression, I would conclude that the viable cancer is likely pretty resistant to it. On the other hand, if there had been little or no progression on it, it would remain high on my list of options to pursue in the event of evidence of new/progressing cancer.

Good luck.

-Dr. West

Reply # - March 26, 2013, 06:36 AM

hobbes
Posts: 12

Hi, We just got good news that my husband's lesions are still very indolent and each is less than 1 cm. The radiologist has recommended SBRT since all three lesions are very close together in an area that is less than 4 cm. The surgeon has suggested a wait and see approach either with or without tarceva. He's been on Tarceva for the past 2 years and altho the lesions have grown slightly and become a bit more dense, he hasn't had any new ones. Does it make sense to take stay on Tarceva if he decides to take the wait and see route or is it time for a break? If he waits to do the SBRT, could it still be done on the individual lesions in the future? Thanks again for all of help.

Reply # - March 26, 2013, 12:11 PM

catdander
Posts:

Hello hobbes, I really like the algorithm linked to in a post above. The big issue is is there room for individualization and it sounds like y'all may be at that point? With stage IV less is more if the cancer is staying relatively put. There may come a time when radiation can make a dramatic difference in his life and you'll want to be able to use it then.

There's no way to know if his cancer would remain indolent unless he is completely off treatment and watched closely.

Of course I'll let Dr. West speak for himself. In the meantime I'm just a bystander with an some information.

All the very best,
Janine
forum moderator

Reply # - March 26, 2013, 12:18 PM

catdander
Posts:

I just want to add, first I imagine you know this. For a few people there is what is known as the rebound effect with tarceva, where the person has fast growth after coming off tarceva. It would be something you'd want to discuss with the doctor so to make arrangements for close and watchful followup.

Reply # - March 26, 2013, 09:44 PM

Dr West
Posts: 4735

I can't comment on whether he should stay on Tarceva, as that gets into the range of giving medical advice, and this is all judgment, no actual data to base a recommendation on. I also can't say whether it's better to be on Tarceva when there's a very small amount of asymptomatic cancer and continue it until the cancer progresses through it, or whether it's better to reserve it for a time when the cancer is symptomatic and a treatment like Tarceva is more clearly needed.

SBRT should remain an option of the lesions don't become markedly larger, or there isn't spread to more distant areas, in which case, a focal therapy like SBRT really wouldn't make sense. I must confess that I'd be concerned that several lesions in the same area would have a real risk of not representing every last bit of the cancer, so it's not clear to me that there would be a value in radiating several very slowly growing lesions.

Good luck.

-Dr. West

Reply # - March 28, 2013, 01:46 PM

hobbes
Posts: 12

Thanks so much Janine and Dr. West. He's decided to take a wait and see approach and has scheduled a follow up scan in four months (and hopefully at least another 4 months after that etc.) One of the doctors has suggested that he add avastin to the tarceva to see whether it would help to slow down the progression a bit. I read on your posts Dr West from about a year ago where you aid that sometimes insurance doesn't cover both because the combo wasn't FDA approved and that that combo isn't used very often. Have you learned of anything new about taking tarceva with avastin together; are doctors starting to recommend this more frequently? Is there any data to suggest that pairing the two might be more effective than just taking tarceva alone? Thanks again for all of your help.

Reply # - March 28, 2013, 09:23 PM

Dr West
Posts: 4735

It's been studied, and the trials (ATLAS, BeTa if you want to search this site for discussion of the question) has shown trends of modest benefits with the addition of (bevacizumab) to Tarceva (erlotinib). My perception is that there's a trend toward less Avastin use in this setting over time. The evidence just isn't that compelling , and insurers are getting more restrictive about covering the most expensive medicines primarily or exclusively in the settings in which they're well studied and FDA approved.

-Dr. West

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