My dad continues to improve from his 3 hospitalizations and we met with his oncologist today where it was decided his performance status was between 1 and 2 (from between 2 and 3 a week ago) and that he has been on a nice upward trajectory since completing the radiation to his spine last week. We discussed restarting systemic therapy with Alimta or alternatively entering the MK-3475 trail (assuming the spots seen on his recent brain scan are actually old infarcts) where he would receive the investigational drug or Taxotere. Although I know you can't tell us which route to take, I was wondering if you could let me know if the considerations below are the ones we should be thinking about during the decision-making process:
Alimta - Well tolerated; traditional chemo so more chance of a response or stable disease based on an initial response to first line chemo
Taxoter - Not as well tolerated as Alimta; traditional chemo so more chance of a response or stable disease based on an initial response to first line chemo
Mk-3475 - Seems to be have a good side effect profile; not conventional chemo so "responders respond" might not be applicable here; possibility of a longer duration of response compared to conventional chemo
Are there any other considerations that I should be thinking about? Additionally, does anyone have any insight into how soon the first lung cancer immunotherapy will be approved by the FDA?
Thanks so much,
Seth
Reply # - August 6, 2014, 07:19 AM
Reply To: At a Crossroads
When there is a choice between a clinical trial and an off-protocol option, I tend to favor the protocol. First, it moves the field forward, and it often offers the opportunity to receive more treatments over time. Specifically, if you're choosing between Taxotere (docetaxel) vs. MK-3475 on study and Alimta (pemetrexed) off protocol, you can do the Alimta any time, but you will likely only have a limited opportunity to pursue the trial, which is currently the main way we can pursue an immunotherapy for patients with lung cancer.
Yes, Taxotere can be challenging, but the actual evidence in a direct head to head trial of Taxotere vs. Alimta was notable for how similar the side effect profiles actually were, at least for everything outside of blood count drops, which were worse with Taxotere (but we often give G-CSF with Taxotere and can offset that issue). Outside of hematologic side effects, the side effect profiles were the same, even though we largely perceive and talk about Alimta as being way easier to tolerate. The true evidence shows no real difference when scrutinized carefully. I think the issue is that a significant but unpredictable minority of people really have a hard time with Taxotere, and they tend to be memorable to us. We don't yet understand which patients are more prone to significant side effect problems.
But because Taxotere is on the short list of agents that significantly improves survival in patients who have already received chemo for NSCLC, it's among the agents I consider most active in NSCLC and definitely recommend that the vast majority of my patients receive at some point. If it's not going to get easier to tolerate over time (which it almost never will), there's no advantage to deferring and deferring and potentially never getting to it.
Alimta is also a great drug for non-squamous NSCLC, but if it can be given any time, I prioritize the option that maximizes the treatments available to a patient over time.
Good luck.
-Dr. West
Reply # - August 6, 2014, 05:23 PM
Reply To: At a Crossroads
Thank you Dr. West. It is very helpful to know that Taxotere will not necessarily have a worse side effect profile than Alimta. At this point we are leaning towards the trial, but my dad has to have another brain MRI before we can get the go ahead.
Best,
Seth
Reply # - August 6, 2014, 05:27 PM
Reply To: At a Crossroads
Good Luck Seth and dad.
Reply # - August 6, 2014, 05:32 PM
Reply To: At a Crossroads
Thanks Janine! I will update as our path becomes clearer.
Reply # - August 6, 2014, 08:12 PM
Reply To: At a Crossroads
I'm asking here, among the side effects of Taxotere there is the complete loss of hair, right? And peripheral neuropathy as we well? For some reason I knew that Alimta does not have such side effects (or, at least, they are infrequent).
Reply # - August 6, 2014, 08:37 PM
Reply To: At a Crossroads
Hair loss is very common/likely. Neuropathy is uncommon except with prolonged treatment and tends to be rather mild/modest when it happens. It isn't experienced by most patients.
-Dr. West