Secind line KRAS + - 1259696

sergiu
Posts:12

Hallo Dr West.
I am from Romania, my mom was dignosed one year ago with NSCLC, large cell, 3,5 cm lung tumor, 1 brain met (removed).

- Carboplatin + docetaxel + radiaton = 80% tumor reduction
- 6 monts later the same tumor grew back to 3 cm.
- Radiooncologist sai we will not radiate again, we keep radiation as a lest resort in case it will penetrate the mediastinum.
- Now she is taking Tarceva (KRAS positive) for over a month now, but I donț think it is working since her couh got worst, and she is having pain while coughing for a week now (nothing extreme). Plus she is tired at night.

Otherwise she is really well, strong, active and working, hower really sleepy at night. Beseides the cough and tiredness at night, you could not tell she is sick.

What would some viable treatments be?
Coul alimta work since she had platinum based therapy in the past?
Would gemzar be a better option?
What do you think is her best chance? What other treatments do you think is sutable in this situation?

Are the any active trials on selumetinib in romania? How/ Where could I find out?

Sorry fot the many questions, hoewer as you ca imagine, for me all of the seem crucial....

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Reply # - October 6, 2013, 06:19 PM

Dr West
Posts: 4735

You would need to speak with an oncologist in Romania about trials there.

Alimta (pemetrexed) is FDA approved for people with non-squamous NSCLC, including large cell, but it is not clear that Alimta is active in that relatively under-studied situation. It is a reasonable option to try, and it is the only remaining treatment that is commonly used for previously treated patients with advanced/recurrent NSCLC.

Otherwise, Gemzar (gemcitabine) or Navelbine (vinorelbine) are reasonable commercially available options that may possibly have activity, but there is no way to say that any of these is clearly a best choice.

Good luck.

-Dr. West

Reply # - October 7, 2013, 02:20 AM

sergiu
Posts: 12

Thank you for you time and patience.

I have read the Alimta is a poor choice as a second line in patients previously treated with platinum based compunds:
http://annonc.oxfordjournals.org/content/14/3/455.short

Hoewer, gemzar seemed to work well as second line for pepole previously treated with platinum base regiments (no control group):
http://jco.ascopubs.org/content/17/7/2081.short

Taken all this into account, wouldn't gemzar be a better option in this case?

As I said, she is taking Tarceva, but her cough and recent pain during cough makes us think is not working. Hoewer, since according to the last CT a month ago she has no methts, only the primary tumor, her great reaction to the last treatment (70-80% tumor reduction) and that she feels really good and strong, we are still hoping.....at least a little.

Thank you again.

Reply # - October 7, 2013, 05:29 AM

JimC
Posts: 2753

Hi sergiu,

The Alimta trial you cite does not suggest that Alimta is not effective for patients previously treated with platinum. Rather, the results simply bear out the fact that patients who progress through initial chemo do not tend to respond as well to any second line treatment. And since a platinum-containing regimen tends to be the best choice for first line therapy, those patients who progress through it are unlikely to respond to subsequent chemo. The patients who didn't receive a platinum doublet did better, not because they didn't receive platinum, but rather because they hadn't received as rigorous a first-line therapy and their cancer was not as resistant to chemo. It is extremely likely that if the second trial separated its participants on the basis of platinum pre-treatment similar results would be seen.

Also, it's not possible to compare response and survival statistics from one trial to another. The patient group in each trial is different. The only way to directly compare two drugs is to test them against the same patient population.

Although both Alimta and Gemzar are good choices for second line treatment of NSCLC, Alimta has been more thoroughly tested in that context, as Dr. West pointed out. For example, here in the U.S. it is one of three drugs approved by the FDA for second-line NSCLC treatment (the others being Docetaxel and Tarceva).

Good luck with your mom's next treatment choice.

JimC
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Reply # - October 10, 2013, 11:35 AM

sergiu
Posts: 12

Thank you for the opinion.

We had a CT, and the Tarceva did not work, 1 cm growth, no mets, no adenopaties, after 40 days of treatment.

I have a new dillema, and if any oncologist are reading this, I would greatly apreciate an opinion.

One of the oncolgists here, said we should try docetaxel again, another said we should try something else(alimta/avastin/gemzar).
The argument favorig the docetaxel, was that alimta and avastin are more suitable for adenocarcinomas, not large cell neuroendocrine(my mothers), and enough time had passed since they last gave her this medication (aprox 8 months since last docetaxel).
So basicly, one oncolgist said docetaxel again, another said not docetaxel.

We really need somme professional opinions since the ones we got are contradictory.

Please excuse my english.
Thank you.

Reply # - October 10, 2013, 12:32 PM

catdander
Posts:

Your english is excellent. I will contact a doctor for input.

I hope your mom does well with her new treatment.
Janine

Reply # - October 10, 2013, 06:16 PM

Dr West
Posts: 4735

There's reason for controversy, since this is a question of judgment, not one with a clear answer. If there wasn't progression on docetaxel previously, I would consider it very reasonable and perhaps the best idea to resume docetaxel. I would really be inclined to move away from it only after clinically significant progression through docetaxel has been demonstrated, but not necessary if it was stopped just because a fixed duration of treatment had been completed.

As I mentioned in a prior response, I share the concern that Alimta may not be a strong choice in patients with a neuroendocrine carcinoma.

Good luck.

-Dr. West

Reply # - October 10, 2013, 09:48 PM

sergiu
Posts: 12

I am really concerned about the huge toxicity of docetaxel and I dont know if mentally she cand go tru it again.
One of the mentioned combo was avastin/gemzar, leaving docetaxel as a last line of option.
What do you think about this choice?

Reply # - October 10, 2013, 10:16 PM

Dr West
Posts: 4735

It is a reasonable consideration, I suppose, but not well studied. I have never given it, and there is no evidence of it in lung cancer. It really isn't possible for us to make recommendations among various options that all have no evidence comparing them.

-Dr. West

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