Stage 4 Adenocarcinoma - Chemo regimen question - 1263485

Hi semone12,

Good to hear that so far your mom is tolerating Carbo/Alimta well. In most cases, adding Avastin does not worsen treatment side effects significantly.

The trial evidence in favor of adding Avastin to a two drug platinum combination is mostly from the initial clinical trials with Carbo/Taxol. As Alimta has become a common substitute for Taxol, many oncologists assumed that Avastin would confer a similar benefit when added to Carbo/Alimta.

The issue of whether Avastin is a valuable addition to first line therapy has been discussed here on GRACE previously:

http://cancergrace.org/lung/2009/07/24/patel-regimen-rs/
http://cancergrace.org/lung/2013/06/17/pointbreak-maintenance-therapy-u…
http://cancergrace.org/lung/2013/06/14/pronounce-trial/

JimC
Forum moderator

As Jim indicated, the answer is very equivocal. The fact is that beyond a single trial, Avastin bevacizumab) hasn't been shown to improve survival, and I would say that most lung cancer specialists consider it an option but definitely not a mandate (though there are a few outlier opinions out there that it should be added, it's important to watch that the materials you're reading aren't sponsored by the makers of Avastin). Particularly in patients over 70-75, there is some evidence that the side effects may exceed the beneficial effects of the agent added to chemo. But even in younger patients, the fact that it has never demonstrated a survival benefit in any other trials beyond a single one leads most people to believe that it's a fine option but hardly a wildly compelling core component of treatment. In fact, a trial last year of carbo/Alimta (pemetrexed) without Avastin (bevacizumab) showed survival very similar to an Avastin-containing regimen.

I think it's a strong consideration in younger patients, a pretty dubious one for older patients, and overall it hasn't made a clear case for being a critical component of the regimen. Only a minority of people in the US actually get it (about 25-30% of NSCLC cases), as many have some factor, whether related to age or potential complications from other medical issues, that makes it a questionable choice.

-Dr. West

With regard to brain scans at initial diagnosis, Dr. West has said:

"Brain imaging is typically part of the workup for a newly diagnosed lung cancer, since brain metastases are not uncommon and can definitely been seen even in asymptomatic patients. Though we never want to find them, it’s helpful to detect them when small and solitary, rather than because several large ones are present and lead to a seizure as the first sign of brain involvement. It also tends to be helpful to have a good sense of the full extent of disease at baseline, so that if brain metastases become apparent later, you don’t have to guess whether they were there previously or not." - http://cancergrace.org/topic/need-for-base-line-ct-or-mri-of-brain#post…

And Dr. Weiss has said: "I typically acquire an MRI at diagnosis, then again if symptoms suggest." – http://cancergrace.org/lung/topic/should-brain-mri-be-done-even-in-abse…

As far as the difference between CT and MRI for detecting brain lesions, Dr. West has said:

“There is little to no question that head MRIs are superior to CT scans in detecting brain metastases. MRI scans detect a greater number of lesions and defines the location more readily, and they are also better at detecting spread to the meninges, the lining around the brain (and spinal cord).” – http://cancergrace.org/lung/2007/04/05/intro-to-brain-mets/

JimC
Forum moderator

In the US, the current standard is really to do brain imaging as part of initial assessment of advanced lung cancer. PET/CT scans are not really able to provide the detail to rule out brain metastases.

-Dr. West