This is how it stands with me... - 1257644

Margo,

We can't answer "should" questions, since that's asking for medical advice that we're not legally able to give. It's always reasonable to seek a second opinion when you have questions that you'd like clarified or simply want reassurance that the track you're on is right, or else to learn of some other alternatives. If you learn that the opinion is in agreement, you at least have the reassurance of a confirmation. If the opinion is different, you get another perspective that might provide a new helpful option

Surgery is not standardly recommended for patients with stage IIIB NSCLC, so it's definitely appropriate for that to not be the favored approach.

Similarly, Tarceva is not a standard recommendation after chemo/radiation and has no established role here. Accordingly, I think the question is more why it was pursued than why it is potentially being discontinued.

If you have specific questions, feel free to pose them as follow-up questions, but it will be better to articulate a clear question rather than to just ask for comments from the faculty. Please just make it a specific, closed question and not just a solicitation for medical advice.

Good luck.

-Dr. West

There aren't medical reasons for stopping tarceva other than significant progression or side effects. There have been issues with paying for the drug however at least in the US the drug manufacturer have helped in that case. May I ask why you ask?
Have you read this? It speaks about about acquired resistance to tarceva, http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/

I'd just add that in someone who has an activating EGFR mutation, we'd be extremely reluctant to stop Tarceva (erlotinib) completely, because such patients tend to have such an excellent benefit from Tarceva. Instead, such patients can still benefit from Tarceva at a much reduced dose, one that is tolerable, rather than discarding a potentially very effective treatment just because the standard dose is excessive for some people.

-Dr. West

As I'd said in my first reply on this thread, the experience with Tarceva is almost exclusively in people with stage IV NSCLC, where we can't realistically expect that our systemic treatments will kill all of the cancer. Consequently, in that setting, Tarceva is continued indefinitely. In earlier stage disease, where people may be cured, there's no established role for Tarceva, so there's also no clear duration of therapy to pursue.

-Dr. West

While Tarceva is only well studied for patients with metastatic NSCLC, we know that it's often an extremely effective therapy for patients with an activating EGFR mutation. Because of this, it's extremely tempting to want to give it to people with an EGFR mutation even if they don't have advanced NSCLC. However, in a situation in which people may be cured without Tarceva (such as stage I - III NSCLC), it's never clear whether the cancer is cured (perhaps cured because of the Tarceva, but perhaps would have been cured without it), or whether the cancer is only being suppressed because of the Tarceva. So there's no clear answer to how long to treat when people may be cured even without the Tarceva, in which case it's possible that the Tarceva is just being continued as a superstitious practice.

-Dr. West

The question of whether, how, and for how long to use Tarceva in an earlier stage patient with an EGFR mutation is really an open question. While it doesn't have an established, proven role, it's completely understandable why someone would want to recommend it in that setting, and some experts do advocate that, even if there's definitely nothing close to a consensus on the best way to approach this situation.

-Dr. West