My dad was diagnosed with stage 3B squamous lung cancer in June 2012. He received two cycles of gemcitabine + cisplatin which resulted in stable disease in July 2012, and in September 2012 received radio therapy with concurrent docetaxel + nedaplatin. The tumor responded well to the concurrent radio-chemo and shrinked by half in diameter. He relapsed in March 2013 and since then recieved four cycles of irinotecan plus nedaplatin, to which he initially got a partial response but soon progressed on therapy. Since this last progress his health has been gradually deteriorating, with more cough, pain, fever and short of breath.
Currently he's taking erlotinib and it's been three months. The TKI greatly improved his symptoms in the first month but everything is coming back now. We are considering a chemo now but have no idea which one is the best bet. I know the probability of a response is low after so many pretreatments but still don't wanna give up. Currently his performance status is probably between 1 and 2. Here is what I'm considering now:
1. Singlet docetaxel. He responded well to the concurrent radio-chemo. If that was partly due to docetaxel then we might have a chance with a rechallange given that he's been off that drug for more than a year.
2. Abraxane, singlet. The first-line data is promising but I don't know how much it means to us in such a heavily pretreated setting. Also, it is very expensive to us.
3. Irinotecan, singlet. This is the only chemo he was confirmed to respond to. Again, I'm hoping to get a rechallange response.
Sorry about the long description. Any advice, suggestion would be greatly appreciated! Btw, my dad lives in China so doesn't have access to many of the exciting trials conducted in the States. Thank you!
Reply # - February 12, 2014, 01:37 PM
Reply To: Asking for advice on lung SCC treatment
Hello Ashley, I did a search of recruiting trials in China currently studying nsclc. I know travel is an issue for a country that size, http://clinicaltrials.gov/ct2/results?term=nsclc&recr=Open&cntry1=ES%3A…
There are options that may be available options in China including docetaxel (brand name taxotere) and gemcitabine. Alimta shows no efficacy on squamous tumors and avastin too often cause bleeding. Following is a link to a blog post on second line treatment though it's a general rule that it includes treatment options for 3rd, 4th, etc. lines. http://cancergrace.org/lung/2010/10/04/lung-cancer-faq-2nd-line-nsclc-o… and http://cancergrace.org/lung/2006/11/14/treatment-after-initial-chemo-in…
Generally oncologist don't go back to a treatment. Though they sometimes do if it was stopped with no progression such as after a certain number of treatments; in your dad's case gemzar and docetaxel is an example.
Platinum based chemo is usually stopped after 4 or 6 cycles because of the possibility of hypersensitivity is so high after that.
Please ask followup questions as you read and as questions develop.
All the best to your father,
Janine
Reply # - February 12, 2014, 08:42 PM
Reply To: Asking for advice on lung SCC treatment
You're right that there are some complex issues here. I would say that the weakest choice is irinotecan if he progressed on it already. Docetaxel is the only one that has a proven survival benefit, but I think that may be a real challenge for someone with a marginal performance status. Abraxane has the advantage of being weekly, so there is the opportunity to check on the tolerability week to week, and it appears to be particularly active against squamous NSCLC. We can't tell you what to do, but I think those are the strong options.
Good luck.
-Dr. West
Reply # - February 13, 2014, 06:31 PM
Reply To: Asking for advice on lung SCC treatment
Hi Catdander and Dr. West,
Thank you for your prompt responses and the valuable information given. It's amazing that there are people like you giving help like this.
Yes I am aware that the general practice is not to use a drug that was used before. But I recently came across a paper published on Nature Reviews Clinical Oncology titled "Drug rechallenge and treatment beyond progression", which reviewed various clinical data that suggest rechallenging with a drug that was initially active may be a viable option for patients with relapse or recurrent disease. This might be rude but Dr. West, may I ask what is your opinion on this matter, I mean, on drug rechallenge? The paper discussed various types of cancers and a range of different drugs. I know different cancers behave very differently, even the 'same' type of cancer are not like each other. Therefore, I'm keen to hear what a specialist with a lot of experience in lung cancer would say.
Btw here's the link to the paper http://www.nature.com/nrclinonc/journal/v10/n10/full/nrclinonc.2013.158…
Reply # - February 13, 2014, 09:34 PM
Reply To: Asking for advice on lung SCC treatment
That subject has been addressed by Dr. West previously:
"We might sometimes return to a chemo on which someone had a response and then had it discontinued because they reached a fixed amount of treatment, but we don’t generally return to a chemo treatment on which a person progressed." - http://cancergrace.org/topic/revisiting-former-chemo#post-1248780
And Dr. Pinder agreed:
"Whether or not I would have a patient go back to a previously effective regimen depends on why the regimen was stopped. Now that I have some patients on 5th/6th line therapy, I find that I am sometimes going back to previously effective regimens that were stopped to give a patient a treatment break. When a treatment was stopped for progression I do not go back to it." - http://cancergrace.org/forums/index.php?topic=2123.msg12629#msg12629
JimC
Forum moderator
Reply # - February 13, 2014, 10:27 PM
Reply To: Asking for advice on lung SCC treatment
I have actually favored the idea of questioning the dogma about returning to a prior therapy or treating with an agent beyond what is strictly termed progression, but that's really an idea that is being liberalized only in particularly settings, and this isn't one of them. If someone had been treated with a targeted therapy like Tarceva for 2 years, had a wonderful response, then demonstrated some mild progression with a few new lung nodules but far less cancer than they started with, it makes good sense to continue treatment beyond the first evidence of progression. If someone came off a therapy a long time ago but had previously responded well, it's very reasonable to rechallenge, particularly if there are few or no other appealing options.
This concept of rechallenge or continuing beyond progression is not very appealing in the setting of a short, very limited response to a treatment before the cancer progressed on it.
-Dr. West
Reply # - February 14, 2014, 10:24 AM
Reply To: Asking for advice on lung SCC treatment
I consider weekly paclitaxel a strong choice. That is usually easy to take, and it is very low cost. If he does poorly on that, then consider no more chemotherapy. You could also ask about vinorelbine. Hope this helps.