I was diagnosed with stage IV NSCLC last November and have been on Xalkori since then. I had eight very tiny mets in the brain that all were successfully treated with the gamma knife. My latest MRI indicates that my brain is clean and my latest chest CT indicates that the pleural thickening, which was the only positive finding in my chest at the time of diagnosis, is markedly improved. Although Xalkori is working wonderfully, we know that it does not "kill" the cancer cells but simply keeps them under control. My question is whether at this point something should be done to try to actually kill the cancer in my chest, such as undergoing regular chemotherapy and radiation, or whether the only thing that can be done is to keep taking Xalkori and change to another drug when it stops working.
Alternatives to Xalkori - 1258644
tjames
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Reply # - August 16, 2013, 10:32 AM
Reply To: Alternatives to Xalkori
Hi tjames, I hope you are feeling alright. That's a very difficult question. I will ask a doctor to comment.
All best,
Janine
Reply # - August 16, 2013, 01:13 PM
Reply To: Alternatives to Xalkori
Crizotinib is approved for use for EML4/ALK rearranged stage IV NSCLC. Stage IV lung cancer is when the cancer has spread (metastasized) and is not curable. But, incurable and untreatable are not the same. The goals of treatment for incurable cancer are twofold: increase quality of life and increase duration of life (both compared to doing nothing). While we’d love to cure stage IV lung cancer, we don’t know how yet. Until the day that we learn how to cure stage IV disease, I think that these goals are worth pursuing. Every time that I make a decision with my patients, we come back to these two questions like a broken record: will the proposed maneuver increase quality and duration of life or will they decrease it?
You asked about stopping a targeted therapy that’s currently working to switch to chemo or XRT with the goals of killing more cancer cells. It is possible that a switch to radiation or chemo would kill more cancer cells. It is also possible that by stopping crizotinib, you would disinhibit the growth of cells that are being held in check by it, leading to more total cancer. More importantly than killing cancer cells per se, is to ask, “Which maneuver (continuing crizotinib or immediately switching to chemo or radiation) would best maximize quality and duration of life?”
While crizotinib is certainly not side effect free, the typical side effects are gentler than chemo. Further, crizotinib tends to control cancer growth better and so is more likely to minimize cancer related suffering. So, for quality of life crizotinib wins. Based on our existing data, it ‘s likely to be better for survival too. Finally, as a general principal, we don’t usually stop a well tolerated therapy while it’s working.
The question of radiation is harder and cannot be addressed properly in this forum. While it’s not standard of care, I do sometimes “break the rules” and consider radiation in metastatic cancer if there is only one small spot of visible cancer. TBC..
Reply # - August 16, 2013, 01:14 PM
Reply To: Alternatives to Xalkori
(Cont)
Things that push me towards doing it are limited area of cancer, high safety of radiation to the specific location, and location where growth would be a threat. The value (or lack thereof) of considering “breaking the rules” in such a situation is best evaluated in a multidisciplinary tumor board including expert medical oncologists and expert radiation oncologists who specialize in lung cancer. It’s certainly not standard, but can be reasonable in specific situations.
It's also important to note that there are multiple promising strategies for treating resistance, once it develops, to xalkori that aim to maximize quality of life, increase duration of life, and delay the need for chemo.
Reply # - August 20, 2013, 10:09 AM
Reply To: Alternatives to Xalkori
Thank you Dr. Weiss for your very comprehensive reply.
My thinking at this point is that since I am fortunate to be doing very well on Xalkori, perhaps now might be a good time to try and do something more aggressive and definitive, to try and kill the cancer if possible, rather than simply waiting for Xalkori to stop working. I was thinking of radiation to the pleura, even though I don't really know if that is something that is available generally. I understand that as long as Xalkori is working, it would probably not be wise to stop it. Perhaps radiation could be pursued simultaneously.
Maybe I'm totally off base altogether but I was thinking in terms of trying to maximize the chances of a cure, even though I appreciate that a cure for stage 4 is generally not attempted.
Reply # - August 20, 2013, 12:49 PM
Reply To: Alternatives to Xalkori
Hi tjames. I was on Xalkori and was having problems with tumor closing off my airway. A course of radiation to the chest was recommended, to hopefully relieve symptoms, not to cure. I had to stop Xalkori for the duration of the radiation treatment. I don't think concurrent Xalkori and radiation has been studied, so I would expect doctors to shy away from trying that outside of a clinical trial.
Debra