EGFR – Exon 19 deletion - 1263520

tina72
Posts:3

My questions are regarding EGFR Exon 19 Deletion mutation. I just started Afatnib in March (been on medication for 6 weeks) after Tarceva stopped working (cleared a scan then showed a lung nodule after 12 months) and Alimta failed (2 additional lung nodules after two treatments).
If the Afatnib doesn’t work, what would you suggest my next route is?

When are new drugs for my mutation being approved?

Should I get a re-biopsied to see if I have anything different then orginial mutation?

Thank you!

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Reply # - May 1, 2014, 05:44 AM

JimC
Posts: 2753

Hello tina72,

I'm sorry to hear of your progression. For the benefit of the GRACE medical faculty, I am summarizing your history:

April 30, 2012 1.8cm lung nodule on my upper right lobe of my lung. NSCLC stage 1A. June 3, 2012 removed right lobe via wedge resection; all 7 lymph nodes tested negative. Told chemo not necessary for my staging. 5 cycles of chemo; started Tarceva February 2013. One lung nodule back after 11 months on Tarceva; two cycles of Alimta. Two new lung nodules; switched to Afatinib.

If Afatinib does not work, your treatment options are most likely a conventional chemo agent such as Taxotere (which is FDA approved for second-line treatment of NSCLC) or a clinical trial of either another EGFR TKI (like Tarceva) or a novel agent with a different mechanism of action.

One consideration in making that choice is the thought that perhaps Tarceva did not "stop working", but that it never did work. Some patients, even those with activating EGFR mutations, do not respond to EGFR TKIs. You had your solitary nodule surgically removed; at that point there was no visible cancer to treat and no way to know if Tarceva was killing any cancer cells. Micro metastasies, invisible on scans, may have continued to grow after your surgery, taking a year for a new nodule to develop and appear on a scan. It could be that your cancer has a component that is not driven by the exon 19 EGFR mutation, and that is the component that grew during your year on Tarceva. But it's also possible that Tarceva was effective against the EGFR-driven component. In such cases, a combination of an EGFR TKI and another agent may be considered.

With those thoughts in mind, you may want to discuss the possibility of a new biopsy with your doctor to see if a new mutation has developed.

Wishing you a good response to Afatinib.

JimC
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Reply # - May 1, 2014, 06:14 AM

tina72
Posts: 3

Well I had two lung nodules before starting Tarceva and they disappeared after 6 months on Tarceva (150mg).

Thanks for the information and will discuss with John Hopkins at my next appointment.

Reply # - May 1, 2014, 06:36 AM

JimC
Posts: 2753

Yes, that is significant, indicating that Tarceva was effective for a time but that your cancer may have developed resistance to it. That would strengthen the argument for a new biopsy and/or choosing conventional chemo or a novel, non-EGFR TKI trial drug.

JimC
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Reply # - May 1, 2014, 06:58 PM

Dr West
Posts: 4735

Aside from chemotherapy, as Jim noted, there are some new treatments emerging in clinical trials that have been promising for acquired resistance. Here's a link that describes a couple:

http://cancergrace.org/lung/2014/03/09/new-agents-for-acquired-resistan…

Also, the combination of afatinib and cetuximab has looked encouraging, though I think it would not be as strong a consideration in someone having already been on afatinib.

http://cancergrace.org/lung/2011/06/09/janjigian-acquired-resistance-to…

The combination really needs to be tested further in clinical trials before any more definitive statements can be made about it.

Good luck.

-Dr. West

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