Tarceva without EGFR result - 1262926

Hi gigy,

To use tarceva for first line treatment there needs to be proof that an EGFR mutation is present. However tarceva can be prescribed to any nsclc patient going into 2nd line treatment. So some people who aren't comfortable waiting so long for results can start chemo treatment. But it's a decision that needs to be made between doctors and patient.
If I may ask, what did your doctors say about the met in the brain? Often brain mets are the first focus of treatment because they can be the most harmful.
Also radiating painful bone mets can bring quick relief and I recall you have suffered from that as well.

I hope you get things figured out,
Janine

Janine's quite right. The results of the IPASS trial, done in Asian never-smokers or former light smokers with an adenocarcinoma (clearly enriched for a high probability of having an EGFR mutation) clearly demonstrated that even with all of the factors suggestive of having an EGFR mutation, 40% of the people on the trial didn't have an EGFR mutation, and those patients did FAR better with initial chemotherapy than with initial Iressa (gefitinib). Similarly, the TORCH trial done in Europe clearly demonstrated that in a population that wasn't "molecularly selected" (not tested for the presence of an EGFR mutation before the start of treatment), the patients who started with initial Tarceva (erlotinib) did especially poorly, too often declining to the point of not being able to get chemotherapy after progressing on early EGFR inhibitor therapy. Because of this, there's a clear set of rules that have developed, based on good evidence:

1) If a patient isn't progressing too quickly or isn't too anxious, it's great to get molecular marker data before initiating first line treatment.

2) If a person has an EGFR mutation, start them on an EGFR tyrosine kinase inhibitor (TKI) as soon as feasible. If they've already started on chemo, you can switch them right away, but more often we favor seeing how they're doing on chemo and then transitioning to the EGFR inhibitor either as maintenance therapy or at the first evidence of progression.

3) If a person doesn't have an EGFR mutation or EGFR mutation status is unknown, you a far better off starting with chemo, which is never clearly wrong since you can transition to EGFR TKI therapy later, but it's not as feasible to start with EGFR TKI and then hope to benefit from chemo.

More here:

http://cancergrace.org/lung/2008/11/03/ipass-mutation-diffs/

http://cancergrace.org/lung/2010/07/02/changing-clinical-practice-the-e…

-Dr. West