Sarcomatoid carcinoma maintenance - 1259402

tvoltagg
Posts:30

My wife has spindle cell (sarcomatoid) carcinoma and has just completed her 6 rounds of carbo/taxol/avastin. Scans started with reduction, then stable. Next scan due next week. Hoping for stable or better.

We are looking at maintenance therapies. Our first choice and hope is to get into the Merck anti PD1 trial here at Penn and have FeistyD's response. If not, our onc suggests continuing with taxol/avastin as maintenance, but I'm not crazy about continuing the taxol. Her side effects are not good on the taxol. Another option is just avastin. My onc doesn't want to use Alimta because it is ineffective with squamous and since sarcomatoid is not like anything else, it could respond just as poorly as a squamous tumor to Alimta (of course it also could respond just as well as adenocarcinomas).

So, I'm interested in people's views based upon their experience for maintenance (or second line treatment) for sarcomatoid histology. Thanks.

Tom

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Reply # - September 20, 2013, 11:18 PM

Dr West
Posts: 4735

I'm sorry that I think you're very unlikely to have anyone here who can comment on what to expect for sarcomatoid histology, since it's so rare. Aside from the promising results in a few patients with this histology who received immunotherapies like anti-PD1 agents, there's really no specific information about it.

Taxol (paclitaxel) is not commonly used as a maintenance therapy, since it has no proven value after 4-6 cycles and definitely leads to cumulative neuropathy.

Avastin (bevacizumab) alone is sometimes used, and it is the more studied approach after carboplatin/taxol/Avastin as first line therapy.

The hesitation about Alimta (pemetrexed) is understandable, since it definitely has some specificity for non-squamous histology and may not have activity in sarcomatoid histology...that's just not known.

Otherwise, Tarceva (erlotinib) and Taxotere (docetaxel) have each been studied as a maintenance therapy and have some evidence for potential benefit as well. That said, there's no established best approach in this situation.

Good luck.

-Dr. West

Reply # - September 21, 2013, 09:24 AM

tvoltagg
Posts: 30

Thank you, Dr. West. Your feedback is greatly appreciated. I guessed that there wouldn't be much of a response due to the rarity, but I thought I'd take a shot.

I do have one follow-up if it is alright. I'm guessing that taxotere is a taxane, therefore much like taxol. If continuation with taxol is not commonly used as maintenance, what makes taxotere different?

Again, thank you for your response.

Tom

Reply # - September 21, 2013, 09:57 AM

JimC
Posts: 2753

Yes, they are both taxanes. Taxotere has been more thoroughly tested in clinical trials for second-line/maintenance treatment. Also, taxol is more likely to depress blood counts, so it's not well suited for use on a relatively long-term basis.

JimC
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Reply # - September 21, 2013, 10:07 AM

Dr West
Posts: 4735

1) Taxotere (docetaxel) is less likely to cause prohibitive cumulative neuropathy (though it definitely can cause neuropathy)

2) Taxotere and not Taxol (paclitaxel) has been shown to improve survival in previously treated patients, and Taxotere actually has been looked at as a maintenance therapy that has proven value in prolonging progression-free survival. It didn't meet statistical significance for overall survival, though it was too small a trial and actually showed an improvement in survival vs. delayed taxotere of over two months. It was actually the best conducted maintenance therapy trial, which is part of why it didn't show a statistically significant benefit (the trials that were statistically positive were designed in a way that handicapped the non-maintenance therapy arms).

In short, my overall sense of the totality of the evidence in lung cancer is that Taxotere is a slightly more effective agent than Taxol in NSCLC, at least in patients who have already received a few months of chemo. I think there's not likely to be any meaningful difference in first line, especially when several subsequent treatments equalize everything, but after first line, the evidence is more compelling with Taxotere.

-Dr. West

Reply # - October 1, 2013, 05:31 PM

tvoltagg
Posts: 30

Unfortunately, scan last week showed progression. Attempting to get in the Merck anti PD1 trial. Biopsy being scheduled. What options are there if PDL1 negative and can't enroll?

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