next steps - 1255047

Hi sonja,

I'm sorry to hear of your Mom's progression. There is some evidence that returning to Tarceva after a prolonged response the first time may provide a benefit. Here is a previous discussion of a small study in which patients returned to Iressa (a drug very similar to Tarceva) after progression on chemo: http://cancergrace.org/forums/index.php/topic,3666.0.html

The topic was also discussed here: http://cancergrace.org/lung/2011/04/24/interview-with-dr-tony-mok-part-…

The three drugs generally approved for NSCLC treatment after first line are Alimta, Tarceva and Taxotere, so Taxotere would also be an option. Although it is also a taxane like the taxol she had first line, there is also good evidence that Taxotere is different enough that it can provide benefit to patients previously treated with taxol.

The main considerations with regard to whether to choose a trial drug vs. established treatment are (1) whether there are good established alternatives and (2) whether choosing another line of treatment will disqualify the patient from entry into the trial (some trials limit the number of previous lines of treatment).

JimC
Forum moderator

Thanks for your kind words about GRACE. I'm glad we've provided helpful information. I'm sorry recent changes have left you in need of help now.

There are a few trials here and there for patients with an EGFR mutation and "acquired resistance", and any of these treatments might prove to lead to good and prolonged responses, but none has risen to the top of the list as a definite thing to try. There is no prevailing standard practice except to move on and treat people with acquired resistance and an EGFR mutation with the same options after progression that we'd use for someone who doesn't have an EGFR mutation -- that said, it's certainly reasonable to add chemo to ongoing EGFR inhibitor if the progression is rather minimal, or possibly to return to an EGFR inhibitor later. I would say that the results of restarting a drug like Tarceva (erlotinib), or for switching to afatinib in the compassionate use trial have not been dramatically beneficial. I have the compassionate use trial for afatinib available at my center and can't muster the enthusiasm to recommend it for most of my own patients with acquired resistance to Tarceva. Both the prior data and my experience with it have led me to the conclusion that it's not especially effective.

I wish I could give you a strong recommendation for an alternative, but perhaps removing the conflict of wondering if you're missing something great is somewhat helpful now.

Good luck.

-Dr. West

Good luck to you and your mother. She's lucky to have you looking after her.

Yes. . .best of luck to her. . .And, please keep us posted.

Laya

Sonja, It's considered fine to assess with CT anywhere from 6 weeks to 3 months. 3 months is on the long side. However if the cancer seems well controlled or there are few treatment options past what is being given many doctors will wait longer between scans as long as symptoms don't increase.
Janine

Hi Sonja,

Usually when a new treatment is started after progression is noted, it is optimal to have a baseline scan not long before beginning the new regimen, then a follow-up scan after 2-3 cycles in order to judge the effectiveness of that regimen, giving the patient and oncologist the opportunity to change treatments if it's clear that the new regimen is not working. As Dr. West has said "my practice is generally to give an initial two "cycles", typically about 6-8 weeks, and then repeat scans. However, in patients who are rapidly deteriorating, that provides a very strong hint that the treatment isn't working, so I move up scans accordingly, sometimes after just 2-4 weeks on a treatment, so we can cut our losses if it isn't working and consider moving on to the next thing." - http://cancergrace.org/forums/index.php/topic,1275.msg7021.html#msg7021

JimC
Forum moderator

Thanks to Jim and Janine for together providing pretty much all of the insight we could offer. Jim's provided my personal approach, but I think any interval up to about 3 months is OK...but definitely most oncologists, at least those in North America, do repeat scans after 6-9 weeks in the absence of some intervening new issues.

Also, my general practice if the counts are low is most commonly to postpone chemo for a week, and if counts are better then, to give both agents together.

-Dr. West