Stage 2 NSCLC adenocarcinoma - chemo strategy question - 1254856

Hello chaya,
It is very worth while to try ensure if your mom needs to put on some weight. Some people find them quite doable. My husband started drinking ensure plus and still finds them helpful. They are 350 calories in about 8 oz.

A second opinion may help if you're not sure about protocol or your mom's ability levels. 2 heads are better than one. http://cancergrace.org/cancer-101/2011/11/13/an-insider’s-guide-to-the-second-opinion/

Stage II resected nsclc has a pretty straight forward protocol. If the patient is physically able to withstand chemo then a platinum doublet given in the standard schedule is the gold standard. Usually started 6 to as far as 12 weeks post op has been shown to add benefit. Dr. Wakelee describe the timing of adjuvant therapy, "There is some data to support chemotherapy as far as 12 weeks after surgery, but if a patient has still not recovered enough for chemotherapy by 12 weeks after surgery, it is unclear that chemotherapy given later than this will be of any benefit". http://cancergrace.org/lung/2010/05/17/systemic-therapy-for-resected-ns…

I hope this helps and please don't hesitate to ask follow questions. We also have an extensive library of informative posts.

Much luck to your mom,
Janine
forum moderator

I can tell you that there's no research about the difference of starting after 6 vs. 8 weeks. We generally try to give chemo in the 5-7 week post-surgery period, because that's what the trials proving the value of post-operative chemotherapy did. The longer you wait after surgery, the greater the theoretical risk of the cancer "taking hold" somewhere else, but there's no magic line that you cross that makes 7 weeks acceptable but 8 weeks unacceptable. This delay must be weighed against the potential benefit of a patient being better able to tolerate the chemo with more recovery time.

Cisplatin/Alimta (pemetrexed) is conventionally given just one day every three weeks. I personally split the cisplatin over two days in order to reduce the risk of major nausea or kidney damage, both of which being ameliorated with the cisplatin split, since there's no hint of evidence saying that it compromises efficacy, but the best studied way of giving these agents is by giving them both on one single day.

It's very reasonable to seek a second opinion, but I can already tell you that there's no good evidence to favor one cisplatin-based regimen over another. People just have their preferred regimen based on the specific subtype of NSCLC (squamous, adeno, etc.), and the only clear consensus among the experts is that there's no evidence to support one "best" regimen.

-Dr. West

There's good reason to be wary about cisplatin in a 78 year-old who isn't bounding back remarkably quickly from surgery. The median age in adjuvant chemotherapy trials for lung cancer is 59-63, about a decade younger than the median age of a newly diagnosed patient with lung cancer in the US, and more than 15 years younger than your mother. Cisplatin can be a bear for someone 20 years younger than her, and while she might do well with it, it's extremely understandable to be cautious.

There aren't studies of cisplatin vs. carboplatin-based adjuvant chemotherapy for lung cancer, but the trials with carboplatin have shown a magnitude of benefit in the same ballpark as with cisplatin, though they were generally underpowered and therefore not able to provide enough evidence to topple cisplatin as the leading gold standard in this setting. But that doesn't mean a carboplatin-based regimen isn't a fine choice. I think individual patients may be far better off with carboplatin than cisplatin. Overall, I think it's profoundly appropriate to individualize the recommendation.

There's no clear answer on the question of neutropenia. Yes, carboplatin is a little more likely to cause problematic low blood counts, but it's possible to give growth factor support to mitigate that risk.

There just isn't a perfect answer of what to do in these situations. If a choice of adjuvant chemotherapy is made to minimize risk of recurrence, it will entail some risk in anyone, and more so in a 78 year old who is recovering slowly from surgery.

-Dr. West

My only other point would be that I think it makes sense to be VERY cautious about recommending adjuvant chemotherapy in a very elderly patient more or less reflexively based on staging that is more a technicality than a clear reflection of risk. If the overall picture is that the risk isn't very high, there is good reason to be very wary about chemotherapy. It shouldn't be undertaken without careful consideration, and if that means seeing a lung cancer specialist for additional input, that might be a good option to favor.

-Dr. West

Hi Chaya,

It's good to hear that your Mom's doctors feel that she is strong enough to tolerate the selected chemo regiment.

As far as blood counts, you should ask her doctor how often he is willing to check them, keeping in mind that each time it's checked blood must be drawn, possibly causing more vein problems. Has her doctor ever mentioned inserting a port to avoid the vein problems?

My wife was always a tough "stick", so we always told the staff about her problems, both at the time of making and appearing for the appointment , and asked for the expert IV nurse. I would also recommend alerting the staff about her previous problems, and do that every time she goes in for an IV.

The alimta prescribing information provides:

"To reduce toxicity, patients treated with ALIMTA must be instructed to take a low-dose oral folic acid preparation or multivitamin with folic acid on a daily basis. At least 5 daily doses of folic acid must be taken during the 7-day period preceding the first dose of ALIMTA; and dosing should continue during the full course of therapy and for 21 days after the last dose of ALIMTA.

Patients must also receive one (1) intramuscular injection of vitamin B
12 during the week preceding the first dose of ALIMTA and
every 3 cycles thereafter.

Subsequent vitamin B12 injections may be given the same day as ALIMTA. In clinical trials, the dose of folic
acid studied ranged from 350 to 1000 mcg, and the dose of vitamin B12
was 1000 mcg. The most commonly used dose of oral folic acid in clinical trials was 400 mcg."
.
Corticosteroid

Skin rash has been reported more frequently in patients not pretreated with a corticosteroid. Pretreatment with dexamethasone (or equivalent) reduces the incidence and severity of cutaneous reaction. In clinical trials, dexamethasone 4 mg was given by mouth twice daily the day before, the day of, and the day after ALIMTA administration." - http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/021462s021lbl…

JimC

Chaya,

There aren't research studies to test every possible variable of how treatment can possibly be given, such as monitoring labs or how the IV is placed.

I standardly have a complete blood count checked 10-14 days after the chemo is given, to test the nadir (low point) in blood counts, then again on the day of the chemo again to ensure that the counts are up to a point safe for repeating it (we have the machine right in our office and get the results within a few minutes). I also send for a comprehensive metabolic panel (CMP), which includes testing for kidney and liver function, once each cycle (typically at the same time as their nadir blood counts are checked, since they can take a day to get back, so I like to have them in advance of their next planned treatment).

If someone has really poor veins, it's often helpful to put in a portacath, which goes under the skin below the clavicle, and which can be removed after chemo is done, or a "PICC" line (Peripherally inserted central catheter), which is basically a very long IV that comes out at the elbow and can be maintained for several weeks or even a few months at a time. You can try to limp by hoping to get a good IV nurse every time, but sometimes it's a fool's errand.

The standard is to start B12 and folate at least 5 days before chemo. There is no evidence at all that giving more than the standard recommendation relayed by Jim improves anything. There is a risk that giving higher does may help rescue the cancer cells from chemo, while the lower doses that are routinely recommended selectively rescue the normal cells but not the cancer cells.

The standard is to give decadron at 4 mg by mouth twice daily for three days, starting the day before the chemo (so given the day before, the day of, and the day after the chemo), every 21 days. It's fine and common to also give some right before the chemo as an anti-nausea therapy.

-Dr. West