Possible Progression and Possible Options - 1256943

Hi panas,

I think the main issue here is the duration of your Mom's response. As you see in the first sentence of Dr. West's post which you referenced, he is talking about a situation in which a patient "has had a great response for a long time." Usually that would mean more than six months, so I'm not sure the algorithm applies very well in this situation.

JimC
Forum moderator

Six months is probably on the bubble for what we'd consider as significant benefit, and I think that our enthusiasm for continuing on the same therapy (which is a key consideration of the algorithm) should be well correlated with that. As Jim noted, six months probably isn't enough to strongly favor staying on it for longer, once you're seeing new lesions. And that fact that it's in a couple of areas, not just one, and there's a new lesion that is more than a centimeter in size would lead me to consider this clinically significant progression that merits a change.

Good luck.

-Dr. West

Regarding new biopsy, that's not the standard of care at this time, though it's certainly helpful in a minority of patients. The main finding that changes treatment plans is detecting small cell lung cancer in the new specimen (about 3-14%), which would lead to a specific chemo recommendation along the lines of what we'd give for first line treatment of SCLC (typically a platinum agent with etoposide). Otherwise, a repeat biopsy is nice and can help us understand the biology better, particularly if you're at a research oriented cancer center, but it isn't helpful enough for enough people that it would be considered a standard, expected intervention to pursue.

-Dr. West

Hi panas,

Carbo/alimta is definitely a commonly-used regimen that is often effective and also often well-tolerated. As far as the addition of Avastin, just yesterday Dr. West wrote:

"It’s not clear how much Avastin (bevacizumab) adds — a single trial showed a benefit with it added to the chemo regimen of carboplatin/Taxol (paclitaxel), but it hasn’t been shown to improve survival in lung cancer in any other trial, leading many lung cancer experts and general oncologists alike to be somewhat skeptical about how much it really adds. I would say that while it may add modestly, it’s not likely to be a critical addition." - http://cancergrace.org/topic/adinocarcinoma-nsclc-iv#post-1257136

For what it's worth, my wife got a very good response from first-line carbo/alimta, with manageable side effects. She also had been offered the addition of avastin, which we declined because of the safety issues you mention. Since that time (2008), it has become obvious that those life-threatening complications occur most often with squamous cell cancer, although the percentage you cite is accurate for non-squamous tumors.

JimC
Forum moderator

Right. It's really a judgment call whether to add Avastin or not. It's very reasonable for patients without a contraindication to it (squamous NSCLC, history of coughing up blood), and there's a little evidence suggesting it adds a bit of a survival benefit, but since other studies have failed to show a survival benefit and there is some added risk with it, I and other lung cancer specialists generally consider Avastin to be an option but not a mandate for eligible patients.

Good luck.

-Dr. West

If you search for the term "mixed response" here, you'll find things I've written and done a video or two about. How to proceed in the face of a mixed response really depends on the balance of how much of a response vs. progression was seen, how we'll tolerated the treatment was, and the appeal of remaining options to switch to as an alternative.

Good luck.

-Dr. West

Hi panas,

There is some concern that perhaps combining chemo with Tarceva might cause antagonism between the two and lessen their effect. In order to avoid that problem, my wife's oncologist had her hold her Tarceva dose for a couple days around the time of her Alimta infusion, following the theory of pharmacodynamic separation, which is discussed by Dr. West here: http://cancergrace.org/lung/2007/08/13/pharmacodynamic-separation/
For what it's worth, the combination worked well for my wife for several months, and she tolerated it pretty well.

JimC
Forum moderator

It's also a combination that I've used in some of my patients who have an EGFR mutation and then demonstrate modest progression on Tarceva. I would say that there isn't any compelling evidence of antagonism between Tarceva and most chemo, and with Alimta specifically, so I am not following an approach of pharmacodynamic separation. However, I think it's a reasonable thing to do, and in fact I would say that there's no clear best answer here. Many ideas are very reasonable, but I definitely recommend for some of my patients and continue to have several doing well on for a long time.

Good luck.

-Dr. West

Hi panas,

Congratulations on the great scan results! The plan makes a great deal of sense...saving Tarceva for possible later use.

JimC
Forum moderator

I agree that the plan your oncologist outlined makes plenty of sense. Congratulations on your good results thus far. Good luck on the maintenance Alimta (pemetrexed).

-Dr. West

Great news!

Laya

Congratulations on the good scans and so sensible a plan.
All best of hopes,
Janine

Hi panas,

As your doctor stated, radiofrequency ablation (RFA) is not a standard treatment for liver lesions, but in some circumstances it can be appropriate. Dr. West and Dr. Weis have discussed RFA for liver lesions previously. Dr. West said:

“To me, one important reason why I’ve never been tempted to pursue chemo-embolization or radiofrequency ablation for lung cancer metastatic to the liver is that it’s so rare that this is a solitary metastatic focus: lung cancer that travels to the liver tends to be so likely to have other micrometastatic disease, or areas of readily visible metastatic spread, that pursuing a treatment with added side effects that is going to be effective at most for just one area of a multi-focal process just doesn’t seem to add clear value. Colon cancer is a different situation, because it’s more common to have one or two metastatic foci of cancer in the liver but nothing else appearing anywhere else for a long time, so it’s not as likely to be a disseminated process. And that’s part of while I consider it to still be a compelling idea in colon cancer but not really in lung cancer. This isn’t to say that I’d never consider it, but I think it would make the most sense if a patient was followed over time and had just a single growing area in the liver with long enough follow-up to feel assured that new disease isn’t likely to pop up within weeks or a few months after undergoing that local treatment.”

On the other hand, Dr. Pennell has said:

“In situations where patients have a dominant liver lesion that is causing pain, and the systemic chemotherapy is either not effective (or not enough) to help, then chemoembolization can be very helpful to shrink the single tumor and relieve pain. In my experience this tends to be better for large tumors while RFA is better for small tumors (although small tumors rarely cause pain in the liver).” – http://cancergrace.org/forums/index.php?topic=8278.msg62414#msg62414

[continued in the next post]

[continued from the previous post]

Dr. West also stated:

“In truth, the situations in which RFA for liver lesions or any other metastases in lung cancer would be a tempting consideration would really be very, very limited (and by that, I mean it’s in the range between rare for NSCLC and pretty close to never in SCLC).” – http://cancergrace.org/forums/index.php?topic=9725.msg77130#msg77130

JimC
Forum moderator

I have no personal vendetta against RFA, but I stand by my comments that it is almost never a valuable intervention for metastatic lung cancer. I think it would make sense in the setting of a solitary liver lesion persisting with no evidence of any active disease anywhere else over a long time, at least 6-12 months. Otherwise, it would just be something to do that has a risk of complications but essentially no forseeable value in the setting of known metatatic disease. In about 14 years of concentrating on treating lung cancer, I don't believe I have ever seen or even heard of a case in which a liver metastasis was solitary and controlled with local therapy that lead to the patient doing better overall because it was so isolated over time.

-Dr. West

That sounds like a very reasonable plan. I have pursued this combination for some patients who received prior chemotherapy.

Good luck.

-Dr. West

Hi panas,

I'm sorry to hear of your mother's liver progression. Taxotere (docetaxel) is certainly an appropriate choice, being one of the three drugs which is FDA approved for second and later line use in NSCLC, more thoroughly tested in that context than other drugs.

Clinical trials of novel therapies could also be considered at some point.

Good luck with Taxotere. I hope it is effective and that your mother tolerates it well.

JimC
Forum moderator

Taxotere has a track record of being among the most active drugs for patients with previously treated advanced NSCLC. However, patients whose cancer has progressed readily on recent prior treatments are relatively less likely to demonstrate a good response to further treatment. I hope she does well.

Good luck.

-Dr. West

Hi panas,

Here’s what Dr. West has written about chemoembolization for liver mets:

“It’s hard to assess without being there to see the extent of disease in the liver, but I’ve never requested embolization in a palliative effort to reduce the challenge to the liver. The embolization procedure tends to be very challenging and toxic to the liver itself, at least in the acute setting, which is arguably justifiable in a curable situation, but I think pretty dubious if you’re trying to prevent future liver damage in an incurable situation (which, I’m sorry to say, sounds like a realistic interpretation). You can definitely see the liver functioning less well in the event of very extensive liver involvement with cancer, but it’s often surprisingly resilient. I’ve rarely seen patients actually decline rapidly because of liver failure far before we would have expected to see a decline from other causes, and I would certainly be wary about potentially making things worse in the short term from the risks of the embolization procedure.” – http://cancergrace.org/forums/index.php?topic=10158.msg81025#msg81025

In the same thread, Dr. Weiss adds:

“I have some experience with chemoembolization from my training. As a resident, I did some oncology under one of the procedure’s inventors. It is mostly used for GI cancers. It can help control disease in the liver, but also can be physically painful and can harm normal liver function. It’s one of those tools that I consider from time to time and have rarely pulled out of the toolbox–for lung cancer, I can only remember doing it once. If it is considered, I recommend that the doctor at least informally consult with someone who does this procedure all the time (typically a GI oncologist who treats liver and colon cancer) to ensure that the patient is a good candidate. If this procedure ever has a role in lung cancer, it should be rare.”

[continued]

(Continued from previous post)

There was a previous discussion of chemoembolization in this context here: http://cancergrace.org/forums/index.php/topic,2828.msg16714.html#msg167… In that discussion, Dr. West posted the following comment:

“To me, one important reason why I’ve never been tempted to pursue chemo-embolization or radiofrequency ablation for lung cancer metastatic to the liver is that it’s so rare that this is a solitary metastatic focus: lung cancer that travels to the liver tends to be so likely to have other micrometastatic disease, or areas of readily visible metastatic spread, that pursuing a treatment with added side effects that is going to be effective at most for just one area of a multi-focal process just doesn’t seem to add clear value. Colon cancer is a different situation, because it’s more common to have one or two metastatic foci of cancer in the liver but nothing else appearing anywhere else for a long time, so it’s not as likely to be a disseminated process. And that’s part of while I consider it to still be a compelling idea in colon cancer but not really in lung cancer. This isn’t to say that I’d never consider it, but I think it would make the most sense if a patient was followed over time and had just a single growing area in the liver with long enough follow-up to feel assured that new disease isn’t likely to pop up within weeks or a few months after undergoing that local treatment.”

On the other hand, Dr. Pennell has said:

“In situations where patients have a dominant liver lesion that is causing pain, and the systemic chemotherapy is either not effective (or not enough) to help, then chemoembolization can be very helpful to shrink the single tumor and relieve pain. In my experience this tends to be better for large tumors while RFA is better for small tumors (although small tumors rarely cause pain in the liver).” – http://cancergrace.org/forums/index.php?topic=8278.msg62414#msg62414

JimC
Forum moderator

To summarize the discussion and not dance around the issue: I wish it were different, but to be clear I would estimate it's value as exactly none. Absolutely no proven or anticipated value in the setting of liver metastases from lung cancer, particularly when it has progressed through prior therapies.

-Dr. West

Hi panas, It's good to hear your mother has responded to the taxotere. Peripheral neuropathy is an unfortunate side effect from taxotere that could easily explain her instability. It's damage to the long nerves of the body (arms to hands and legs to feet). It normally heals when treatment is stopped though the longer it lasts the more likely to experience permanent damage to the nerves.

The forgetfulness could easily be from the chemo treatment though it also could be a symptom of a brain metastasis. Let her oncologist know of the symptom and he/she may want to do an MRI of the brain to make sure it's clear.

I'm so sorry your mother is experiencing these problems. Cancer is nothing less than horrible. Getting a good understanding of what's happening though often impossible is always helpful.

All best,
Janine

Getting 5 lines of chemotherapy is really quite unusual, and the minority of patients who receive that much treatment are very likely to be burdened by the cumulative side effects from all of the extensive prior treatment, also often with cancer related symptoms. So the issues you describe are definitely not typical, but there is no typical for people who have been on so many treatments, and nearly all have battle scars from both the disease and the treatment.

Good luck.

-Dr. West

Hi panas,

I'm sorry to hear of this development. Of course, the development of brain metastases is not good, but radiation tends to be quite effective and often well-tolerated. I hope you can take things day to day and that you begin to see improvement soon.

One question: Has she been put on steroids? They can rapidly reduce swelling in the brain and fairly quickly improve symptoms. If she has been taking them and they have not seemed to help, perhaps it would be worth a call to her doctor to see if the dosage can be increased.

JimC
Forum moderator