CUP chemo drug choices - 1259521

Unfortunately, I think your assessment of the timeline is far more realistic than that of your parents, and I do believe it is a responsibility of the oncologist to offer a realistic assessment of the reasonable probabilities in terms of anticipated benefits and risks of treatments. I would say that a patient can't make an informed decision about whether to pursue a treatment vs. alternatives if he or she doesn't have a fair perspective on prognosis and how much time the treatment proposed might "buy them", especially when there is a considerable cost to the patient and their family.

That isn't to say it's rare to have people avoid this conversation: it's a difficult conversation people want to put off as long as possible, it takes significant time that busy oncologists often don't have enough of in the cancer clinic, and it may lead to a loss of business, whether because patients may well decide that further treatment truly isn't worth the cost (financial and/or side effects) or because many patients never want to have this conversation at all, even if it's the right thing to do. No oncologist wants to be called "Dr. Doom" by their patients, even if it's only for having a realistic discussion to bring them back from the magical world of rainbows and unicorns.

In terms of the regimen selected, it's fine, though very aggressive. I would be very wary that it will be exceptionally difficult for someone who found carbo/taxol and radiation to be very challenging. There is also some risk for complications such as a tracheo-esophageal fistula (a hole that connects the windpipe to esophagus) when Avastin (bevacizumab) is given any time remotely near chest radiation.

The biggest issue is that if his cancer has progressed through prior treatment and he's had a hard time up to this point, further treatment is simply not likely to be very helpful. I'm sorry to say that, but it's important to know that it may just lead to side effects and costs.

Good luck.

-Dr. West

I agree with Dr West, that cisplatin-based doublet chemotherapy in this setting may be difficult for him. It may be reasonable to ask about an alternative, like carboplatin.

Re: $10,000. I doubt that paying out-of-pocket for a alimta or avastin is worth the 'financial toxicity' in this setting. If your insurance truly will not pay for it, then a reasonable alternative to Alimta can be found. Also, Avastin can be omitted without significantly hurting the effectiveness of the treatment. It seems ill advised to be paying for either of those drugs out-of-pocket in this setting.
Similiarly, if a clinical trial is forcing participants to pay egregious out-of-pocket expenses, that is probably a fault in the trial design or trial budget. Sometimes, the trial budget will include an invoice item, if a particular treatment is not covered by insurance. Ultimately, it seems like it would be reasonable to explore other clinical trial options if this issue cannot be settled. Hope this helps.

pbssrs,

That is indeed what Dr. Creelan was saying; although there are many oncologists who regularly use cisplatin (or carboplatin)-alimta (or taxol) plus avastin, the trial evidence for a significant benefit from adding avastin to the doublet is certainly not overwhelming by any means: http://cancergrace.org/lung/2013/06/14/pronounce-trial/

And as Dr. West said in one of his comments earlier in this thread, "there is also some risk for complications such as a tracheo-esophageal fistula (a hole that connects the windpipe to esophagus) when Avastin (bevacizumab) is given any time remotely near chest radiation."

There have been many patients here on GRACE who have responded well to a first line regiment without avastin (including my wife, who had an excellent response to first-line carbo/alimta).

Good luck with your father's treatment.

JimC
Forum moderator

Another consideration is that Avastin can usually be added later, like with round 2 or 3 of the chemotherapy, after the dust settles and issues get ironed out with the insurance company.
As some mentioned earlier, either carboplatin/alimta or cisplatin / Alimta seem like reasonable options in this setting. They have a good track record, even without the Avastin.

First, my sense is that you are reading too much into the "stats" about CUP patients (scant enough to barely merit the term), who are a wildly heterogeneous group. I think you will get far more from seeing the pattern of what is happening in his particular case than from trying to divine expectations from statistics in a relatively small group of heterogeneous patients: CUP isn't the same entity in 20 or 40 people, but rather a smattering of different cancers that don't yield sufficient clues to know with confidence where it started. There is relatively little real evidence about actual protocols in CUP, and essentially none for second line or later therapies in CUP. This doesn't mean that it's unreasonable to try them or to conclude they won't work, but rather that it's necessary to rely on the best judgment of people directly involved, because the "evidence" isn't sufficient to make any clinical decisions.

I agree it's reasonable to put off brain radiation if the issue is just a couple of very tiny, asymptomatic brain lesions. It would be very appropriate to talk about this with his oncologist.

Finally, as your question implied, if there is clear progression on this second, powerful regimen, I think it would be extremely unlikely that the third line regimen would be far more effective, and it would be fair to question the value of additional treatments.

Good luck.

-Dr. West

I completely understand and think you are wise to ask these questions. There is a difference between being negative and being realistic, especially since there are potentially negative consequences for doing treatments that may take a toll on him but have limited prospects of helping.

Good luck.

-Dr. West