Hello,
I am inquiring on behalf of my 70-year old father who lives in India and was diagnosed with non-mucinous BAC in January 2013. Biopsy and tumor marking revealed TTF-1 expression, but negative for ALK1 and EGFR mutations. Surgery was not an option according to his oncologist and was given 5-cycles of pemetrexed (700 mg) / carboplatin (450 mg). He had positive response to the treatment and has been on a maintenance cycle of pemetrexed (500 mg) given every 3-4 weeks since Oct '13. Since being put on a maintenance regimen he has had to deal with bouts of anemia, leukopenia, as well as infections. He also had severe lower lumbar pain for quite some time and his treatment team suspected bone mets as indicated by an MRI scan. However, radiation therapy to the lumbar region did not show any change on the MRI nor did it reduce his pain. In any case, he had a vertebroplasty procedure done recently, which has significantly reduced his lower lumbar pain.
While going through the first 4-cycles of first line chemo, he was able to maintain his weight, but since the 5-cycle and throughout his maintenance cycles, he is struggling to keep his weight because of severe loss of appetite. He hasn't had his maintenance cycle for over 4 weeks now since he is currently around 88 lbs (40 kgs) and his oncologist doesn't think that my dad will be able to tolerate it leading to further complications. Even though he is EGFR negative, the oncologist has suggested putting him on erlotinib to see if it helps. The oncologist feels that my dad may be able to tolerate erlotinib better than the pemetrexed maintenance cycle. A couple of questions:
1. If my dad is able to regain weight and is physically better able to handle the chemo after having taken erlotinib, will there be any impact on the efficacy of pemetrexed if he has to be put back on it (assuming erlotonib doesn't help reduce the tumor)?
2. Is there anything besides pemetrexed that might help as a maintenance regimen?
Thank you!
Reply # - January 20, 2014, 07:23 PM
Reply To: Efficacy of chemo after Tarceva?
Hi pranav,
Welcome to GRACE, and congratulations to your father on his positive response to first-line treatment.
In general the question of whether maintenance results in improved survival remains unresolved. As a result, when a maintenance treatment is not well tolerated, those side effects make the argument in favor of maintenance less compelling. That is why your father's doctor is recommending erlotinib, because it is not chemo and does not tend to be a debilitating as chemo (although it has its own set of side effects).
As far as your specific questions, since your father apparently has not progressed on pemetrexed, there is no reason to think he cannot benefit from it if he returns to it later. On the other hand, when you say "if erlotinib does not help reduce the tumor", that is not really what is expected of maintenance therapy. Of course, if a maintenance drug results in tumor shrinkage that's great, but usually what you're hoping for/expecting is that the cancer remains stable. So if your father remains stable on erlotinib while tolerating it well, there would be little reason to switch away from it.
Also, pemetrexed tends to be one of the best-tolerated chemo regimens, so if your father is having trouble with it, it's not that likely that another drug will be any easier. You can read about maintenance in the GRACE FAQ here: http://cancergrace.org/lung/2010/09/24/lung-cancer-faq-im-coming-to-the…
Good luck to your father with erlotinib.
JimC
Forum moderator
Reply # - January 20, 2014, 08:27 PM
Reply To: Efficacy of chemo after Tarceva?
Jim provided a beautiful explanation of some pretty complex issues here. I have little to add, and I would just underscore that taking a break from treatment is not a disastrous idea, and we readily favor a break if patients are beaten down by the rigors of treatment and the cancer is under control. You can almost always resume later, potentially with the person far better able to tolerate treatment safely, after a break.
There are two main appeals of maintenance therapy:
1) You ensure that patients who responded or at least didn't progress, who are the people most likely to benefit from subsequent therapy, actually get it.
2) With continuation maintenance (continuing one or more agents from first line treatment for a longer period), you don't relinquish the benefit of an effective therapy too soon.
However, there is a competing goal of not wanting to do more treatment than is needed at a given time to control the cancer. Sometimes, that can even be a break from treatment, if you could just as easily restart treatment later. Switching from chemo to Tarceva (erlotinib) is the same idea. If a patient is monitored carefully, I think it's extremely likely that they will do just as well, perhaps even better, after a break in treatment and then picking up later.
The goal is to achieve an optimal balance of good efficacy (controlling the cancer) with as minimal side effects as possible. Longitudinal strategies like maintenance therapy will only be feasible if patients can continue on it without prohibitive toxicities. This is why Alimta (pemetrexed) and Tarceva (erlotinib) lend themselves well, but many other treatments don't. Taxotere (docetaxel) is comparably effective to these agents (probably a shade more than Tarceva in those without an EGFR mutation) but challenging from side effects. Other agents are not likely as effective.
Overall, the plan sounds very appropriate to me.
Good luck.
-Dr. West
Reply # - January 20, 2014, 09:53 PM
Reply To: Efficacy of chemo after Tarceva?
Jim & Dr. West,
Thank you for your quick and very helpful replies. I will convey the information to my dad and report back with the course of action being prescribed by my dad's oncologist and subsequent progress. At this point the oncologist was still debating whether to stay with Alimta (pemetrexed) for another cycle or to switch to Tarceva (erlotonib). I don't think that Taxotere is under consideration given the side effects that my dad has had with Alimta maintenance. Regardless, I will confirm with the oncologist and make sure to include it in my next post.
I am glad to hear that switching to Alimta after having taken Tarceva is not only possible, but perhaps might be better, since it'll give my dad a break from the rigors of chemotherapy treatment (of course, this is assuming that his cancer is sufficiently under control during that break from chemotherapy and that he is in a state to handle the rigors of chemotherapy again).
Thanks once again for sharing your insights, knowledge & expertise and providing guidance here on GRACE.