Stage IV NSCLC - next options?? - 1257405

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Stage IV NSCLC - next options?? - 1257405

My dad was diagnosed 1/25/13 with Stage IV NSCLC with mets to brain & liver.
Dad was always a fairly heavy smoker of menthol cigarettes. He had been previously diagnosed with COPD.
He received whole brain radiation for the brain mets and that seemed to ease the headaches & did shrink the tumors a bit.
The lung tumor is located in the right paratracheal region. He started chemo. He received Carbolatin/Avastin. He did seem to tolerate this ok. No major side effects. He did treatment every 3 weeks, for a total of 3 treatments. The CT showed minimal shrinkage (around 2mm) and also some necrosis was evident. He then took a treatment of Taxotere. That was on a Monday, by Wednesday he was admitted to the hospital with pneumonia. He stayed in the hospital in isolation (due to very low white counts) until the following Monday and was released on Tuesday. It is now Thursday and he is still pretty weak, but doing better.
The latest CT (before taxotere) states there is moderate to severe emphysema. The results of the CT also state "Necrotic aggressive appearing mass of the right paratracheal region with narrowing and invasion of the superior vena cava and encroachment on the ascending aorta" It also says to consider small cell carcinoma or metastatic disease. We had been told previously it was NSCLC.
I am concerned about superior vena cava syndrome. I'm afraid that between that and the severity of his COPD there will not be other chemo that could be tolerated and beneficial. Would Almita?
I am going to the dr. with them on Monday. It doesn't seem like she (oncologist) is very giving on information unless asked. I'm trying to research and have questions ready. I wonder if it's time to discuss pallative care. I know my parents are not ready, but I hate to see my dad suffering.
I appreciate any input or guidance anyone can give.


Reply To: Stage IV NSCLC – next options??

Hi Tina,

I'm sorry to hear about your dad's diagnosis and recent difficulties. It's good to hear that he seems to be doing better.

As far as whether he could tolerate more treatment, that's really a question that only his doctor's can determine, with full access to his medical records and the opportunity to examine him. In general, Carbo/Avastin would probably be expected to be easier to tolerate than Taxotere, which often can be quite challenging. So it's not that surprising that he had a negative reaction to it.

The usual adage is "responders respond", so when first-line chemo is ineffective there is a lowered expectation that changing chemo agents will produce a response. However, in your dad's case his first line therapy was a somewhat unusual combination...typically initial chemo consists of a platinum agent such as cisplatin or carboplatin, plus another agent such as taxol or alimta, and at times avastin is added to the mix. So if they feel he is up to it, his doctors might want to try alimta, which tends to be one of the most tolerable chemo agents available for lung cancer.

As far as his brain mets, when was the follow-up scan done after WBR? Radiation does not simply melt away tumors, so it can take months before its full effects can be seen on a scan, so I wouldn't assume that the tumors only shrank "a bit".

Rather than consider that palliative care is giving up on treatment, if your dad has symptoms or side effects that require palliative measures, it is never too soon to seek such care. I think it would be very helpful if the purpose of palliative care (as opposed to hospice) could be carefully explained to your parents so there is no misunderstanding.

Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

Dr West
Reply To: Stage IV NSCLC – next options??

First, I'd actually be surprised if he received carboplatin and Avastin with nothing else, since it's almost always carboplatin plus another drug with Avastin, most typically Taxol (paclitaxel) or Alimta (pemetrexed). If he really received carboplatin/Avastin, that's quite a deviation from standard, and presumably for a good reason, such as a concern that he couldn't safely tolerate two chemo drugs together with Avastin.

Alimta is often well tolerated, so it's certainly reasonable to consider, but if he hasn't responded well with two prior regimens, it's not likely that a third line regimen will be more effective, I'm afraid.

-Dr. West

Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

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