Scan Frequency While on Crizotinib - 1259004

bdmlu
Posts:16

My son, 33, is six months in to successful treatment with Crizotinib for Stage 4 ALK+ NSCLC. I think the odds that he will be looking at brain mets are increased by 1. The greater than average PFS period he probably can expect, and 2. The debatable efficacy of Crizotinib on the brain as compared to Permetrexed. I want the best early warning/prevention system I can get. Cost always is a factor, but let's say it wasn't. My questions are:
1. What's the optimum interval for scanning, and is it influenced by the fact that he's on Crizotinib?
2. Can Crizotinib and Permetrexed be taken concurrently (or intermittently), and if so could that possibly provide some prophylactic effect against brain mets?
Thanks for any and all input!

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Reply # - September 4, 2013, 01:43 PM

catdander
Posts:

Hi bfmlu, It's good to know your son is doing well on crizotinib. I hope he continues to for a good long time. I will ask a faculty to respond to your posts.

All best,
Janine
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Reply # - September 4, 2013, 09:08 PM

Dr West
Posts: 4735

I'm very sorry to hear of your son's diagnosis, though I'm glad he's doing well now.

Unfortunately, the evidence-based best answer to both of your questions is "we have no idea"; any other answer is just a vague judgment based on our biases.

It's not that these aren't good questions, but these questions have never been studied. There is no evidence that there is anything in this situation that can be done to postpone brain metastases. If brain metastases do occur, there is no evidence that doing brain scans regularly leads to any better outcomes than finding them based on symptoms. It does lead to more brain scans and more anxiety, but not necessarily better outcomes.

Some people have safely received Alimta (pemetrexed) together with crizotinib, but there's actually remarkably scant evidence that Alimta is any good at preventing brain metastases, so I think your premise that Alimta should be a cornerstone of brain metastasis prevention is not founded on much. I also wouldn't presume at all that it's better to give these agents concurrently rather than sequentially. Again, it's possible that it might be, but there isn't a scintilla of an iota of evidence that it is better to give Alimta or another chemo concurrent with crizotinib rather than giving them sequentially.

Good luck.

-Dr. West

Reply # - September 4, 2013, 09:58 PM

bdmlu
Posts: 16

Got it, thanks. I'm just a dumb user, and a new one at that. But I'm trying to take a "no holds barred" approach to my son's disease, so that might lead to some improbable musings on my part!

Reply # - September 5, 2013, 03:35 PM

drdoebele
Posts: 10

I'm sorry to hear about your son's diagnosis. We are now routinely screening ALK+ patients by brain MRI approximately every 6 months while on crizotinib. There is little data on crizotinib brain penetration (although a famous case report suggests it was very low in one patient), but we know that this can be variable from patient to patient. A bit more is known about pemetrexed penetration to the brain which is reasonable, but again this is variable. There are no published studies yet of Alimta + crizotinib. A new cooperative group clinical trial (SWOG 1300) will randomize ALK+ patients who have become resistant to crizotinib to either pemetrexed or pemetrexed plus crizotinib. Hopefully this will give us more information on the safety and efficacy of this combination. I have not been prescribing these agents together because of lack of evidence to support it.

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