NSCLC -Stage 4 -Squamous Cell - Treatment options & Suggestion - 1258870

reply2stevejohn,

Welcome to GRACE. I'm sorry to hear of your Dad's diagnosis, but I'm glad his oncologist has gotten him started on treatment. As Dr. Weiss has said "Gem/carbo is a standard therapy for squamous cell carcinoma of the lung." - http://cancergrace.org/forums/index.php?topic=4732.msg28616#msg28616

And although mutations are less likely with squamous cell carcinoma, they do occur. As GRACE forum moderator Janine (catdander) has written:

"It’s absolutely possible for a squamous only cell lung cancer to have the egfr mutation. certain spring is one such unusual example. Though this is still rather rare it does seem to happen maybe more often than first thought or at least not to be wholely dismissed. For example cs also has a non smoking history which is unusual too though still her cancer was tested more than once for type.

"Here is a new video Dr. West put out on the subject. http://cancergrace.org/topic/brief-video-on-my-changing-perspective-on-… " - http://cancergrace.org/topic/anyone-with-squamous-cell-and-egfr-mutatio…

In his reply to Janine's post, Dr. West said:

" [EGFR mutations are] probably in the range of 1-2% of patients with squamous cell NSCLC, so not common, but definitely possible. Many cancers show some heterogeneous characteristics, so it’s possible that many cases will have a mix of squamous and adenocarcinoma.

"As I mention in the video, we’re still limited by only really finding mutations where you look for them, so we can’t say that much about mutations in squamous cell NSCLC because we haven’t looked exhaustively enough to really know."

With that in mind, you may want to ask your Dad's oncologist about testing for EGFR and ALK mutations, for which there are established therapies.

JimC
Forum moderator

Especially in first line treatment, they would be used sequentially. Later, if a patient has started to develop resistance to a targeted therapy, another drug may be added. Normally you would want to give the current therapy an opportunity to work before switching to something else. Some oncologists will switch as soon as a mutation is discovered, but most will wait to see if the current chemo is effective. There are a finite number of drugs available, so you want to get the maximum benefit from each.

JimC
Forum moderator

I'd say that gemcitabine and carboplatin is a very appropriate first line therapy here, among the more common ones for advanced squamous NSCLC. As far as mutation testing is concerned, "driver mutations" do occur occasionally in squamous NSCLC, though rarely, and at this time it isn't the current standard of care to do molecular marker testing for squamous NSCLC. This isn't to say it's a bad idea, but it's not part of the standard management protocol at this time.

Do you have other specific questions? We don't do interpretation of scan reports and really can't just comment broadly about the overall management of a patient's care. However, if you have a defined, specific question, we can try to address it.

Good luck.

-Dr. West

Hi SteveJohn,

I'm very sorry you dad has been diagnosed with advanced stage nsclc. I understand you are trying to find the info about nsclc so to make sure your dad is getting the best treatment. In fact that is why most people are here so we understand. I don't know that you've seen our library of informative blog posts and videos so I'll link you to a couple are so to get you started. Our search engine is very helpful though you may need to log out to access the results (depending on your browser). We also have several tabs and drop down menus that help navigate around the library.

Let me know if this is helpful and don't hesitate to follow up with more questions.

Janine
forum moderator

http://cancergrace.org/lung/2010/04/05/an-introduction-to-lung-cancer/
http://cancergrace.org/lung/2010/08/22/introduction-to-locally-advanced…

The final answer about how to treat IIIB depends on the individual case. Sometimes a IIIB is so difficult and or dangerous to try to cure that it should be treated as stage IV. Though, if the radiation field is such that it won't be too much radiation then yes radiation should be on the table, again depending, sometimes more is too much. Without it there won't be a chance of cure.
I hope that makes sense, or I should say it probably won't until you've had a chance to digest a bit.

Having pleural-based nodules would put this in the range of metastatic disease (stage IV). There is really no value for radiation in stage IV disease except to treat specific issues like pain, local compressive symptoms, and a few very defined situations. In general, there isn't any role or value in pursuing radiation before chemo for stage IV NSCLC.

-Dr. West

Having definite pleural cancer would make it Stage 4. However, I'm not sure that has been shown your specific case. To me, I am not confident callling the pleural nodule on the opposite chest a definite metastasis, without more context or information. Regardless, this sounds like an advanced lung cancer, and chemtherapy is an important part of treatment. If someone is fit and healthy enough, we will often consider radiation and chemotherapy at the same time for Stage 3B cancers, but this does have many adverse effects too. Good luck.

SteveJohn, I'm sorry but we can't get involved with individual cases as well we can't make suggestions for individuals. It's against the law mostly because it's impossible to make those types of decisions without all the pertinent details of the case. Please read over our guidelines that explain these things. http://cancergrace.org/grace-discussion-forums#guidelines

I completely understand the need to make the right decisions here. As in the link above there is a difference in some cases of stage IIIB nsclc where treatment is based on trying to cure the person of cancer. Other stage IIIB and all of stage IV is treated to extend life and provide better quality of life.

An opinion at a large research center where there are lung cancer specialists is your best bet in receiving the most up to date accurate info. They are able to discuss cases as a team where lung cancer specialist medical onc, radiation onc, and surgeons meet to discuss specific cases. This link explains the many reasons why second (or third) opinions are important. http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide…

I'm not asking you to stop trying to get information from us, on the contrary. We are here to help you understand so you can help your dad.

Janine

Also it's very likely that the treatment your dad is getting now would be the same at this point whether curative or palliative; as you suggested

Yes, I agree with Janine. These situations can be difficult enough to interpret that they're debated even by the doctors directly involved -- and they're all looking at the images and may have all of the relevant details. As doctors not directly involved and without all of the information, we can't get into the individual case details and can't offer medical recommendations.

-Dr. West

Carboplatin with Abraxane is really more studied than cisplatin/Abraxane for lung cancer. The best answer is that there hasn't been enough research on this question to know, but it's obviously most important to pursue the treatment that a person can actually tolerate. Though there is some research that suggests efficacy of cisplatin may be marginally more effective than carboplatin in advanced NSCLC, but nearly all lung cancer experts are very happy to give a carboplatin doublet in advanced NSCLC, especially if someone had trouble tolerating cisplatin previously. Given how much better studied the carboplatin/Abraxane combination is than cisplatin/Abraxane in lung cancer, and how minimal the difference in efficacy is likely to be (if any at all), I have personally only given Abraxane in combination with carboplatin when I've given it as a doublet, and I suspect most other lung cancer specialists would say the same thing.

Good luck.

-Dr. West

I'd have far less enthusiasm for returning to carboplatin in someone who has demonstrated significant progression on it previously. In general, I think that the value of restarting carboplatin would be very minimal, and the potential negative effects likely to exceed benefit, unless carboplatin was just stopped because a fixed number of cycles had been given (we often stop at 3-4 before or after surgery or around radiation, and 4-6 cycles as first line systemic therapy for advanced disease). If someone had progressed significantly on carboplatin previously, I tend to favor either single agent or a "non-platinum doublet" such as gemcitabine/Navelbine (vinorelbine) or gemcitabine with a taxane (such as Taxol (paclitaxel), Taxotere (docetaxel), or Abraxane (albumin-bound paclitaxel)). None of these doublets has a proven value over single agent chemo for previously treated patients, but it's reasonable to consider an individualized approach for specific patient situations.

Good luck.

-Dr. West