Maintenance options after Carbo-Alimta - 1265891

Hi Semone,

Congratulations on your mom's good scan results. A difference of a millimeter or two is not significant, even if it actually exists. But there are so many variables at play, including how a nodule is measured, how the individual CT slices cut and the slight differences between the CT scanners, that you may be talking about a nodule that is completely unchanged. Her scan would certainly indicate stability. As Dr. West has said:

"Imagine slicing an orange. Depending on where you slice it, the diameter of the slice of orange might be different.

A millimeter or two is definitely within the range of error. Studies have shown you can get more variability than that, typically as a combination of slight differences in how the CT slices cut a nodule or mass and how humans measure the nodule. Depending on where and how they measure even the same nodule at different times, or different radiologists having slightly different techniques/interpretation of how to measure a nodule diameter, that error can be several millimeters here or there." - http://cancergrace.org/topic/ct-vs-ct-with-contrast#post-1265007

He discusses the limits of CT scanning here: http://cancergrace.org/lung/2011/08/09/limits-of-ct-scanning/

Although we can't specifically recommend what she should do, taking a month or two off after chemo can provide a welcome break from the side effects of treatment, and when a cancer does not appear to be progressing rapidly, that time period is rarely critical.

I hope she is enjoying her treatment break and good luck with maintenance.

JimC
Forum moderator

Hi Semone,

The question of whether a scan finding showing small increases in the size of nodules indicates progression (especially progression deemed significant enough to warrant a treatment change) is often a judgment call by the doctors most familiar with the patient and her overall situation. In the face of what is at most relatively slow progression, one typical scenario is to keep close watch, scanning again after a fairly short interval and keeping an eye out for new symptoms, to see if there is actually a pattern clearly indicating progression.

JimC
Forum moderator

I agree with Jim's summary, and I'd say that if you have to question whether there is actual progression, it's almost certainly not clinically significant.

One of the main points I try to make is that in the setting of advanced NSCLC, my goal is to have patients do well, with disease controlled (not progressing, and great if it's shrinking) on as minimal treatment as possible. In some cases, that might be NO treatment for a period of time. If someone can do well for the next several months or longer without needing to be on a treatment all of that time, that's perfectly great, as long as progression can be picked up in a timely way and treatment can be initiated again when needed.

Good luck.

-Dr. West

I would also suggest you review this link and the presentation in it for a discussion of the principles of maintenance therapy:

http://cancergrace.org/lung/2014/04/13/what-is-the-value-of-maintenance…

-Dr. West

There wouldn't be a clear value to returning to a treatment on which the cancer has already progressed -- namely, the Alimta (pemetrexed). There is no established role for two drug combinations in the second line setting, and the two best established treatments, which have a survival benefit associated with them, are single agent docetaxel (Taxotere) or Tarceva (erlotinib). In recent years, a couple of trials (one called TAILOR, and another called DELTA) directly compared Taxotere to Tarceva in predominantly or exclusively EGFR wild type (no mutation) patients who progressed on prior chemotherapy, and both showed that Taxotere was a little more effective. Tarceva would certainly be reasonable and would still be a fine choice, but now more lung cancer specialists would favor Taxotere as a second line treatment and leave Tarceva for later.

Other choices are certainly reasonble, but they don't have the evidence to support them and wouldn't be widely recommended.

Good luck.

-Dr. West

Hi Semone,

The typical Alimta dosage is 500mg/m2. If you use the calculator found here the calculated dosage is about 875mg. However, there can be reasons for a doctor to vary the dosage, including a consideration of the overall health of the patient.

Regarding the addition of Avastin, Dr. West has said:

“The fact that the ECOG 5508 trial is testing Avastin (bevacizumab) vs. Alimta (pemetrexed) vs. the combination shows that we don’t know the answer to which is better: that’s really why we’re doing the trial. The AVAPERL study done in Europe really suggested that Alimta/Avastin is better than Avastin alone, but it’s definitely not clear whether the Avastin adds significantly to what Alimta does alone.”

Dr. Weiss added:

“My practice for a PS0 66 year old is to consider using bev and if a patient tolerated pem/carbo/bev well, to consider using pem/bev maintenance. Future data will tell me if what I am doing is optimal or not.”

http://cancergrace.org/lung/topic/alimta-or-alimtaavastin-for-maintenan…

Later Dr. West also said:

"We don’t know if Avastin (bevacizumab) adds anything significant as a maintenance or 2nd or 3rd line therapy. We generally don’t start Avastin after first line, and that’s partly because it’s quite expensive, the side effect risks aren’t negligible (even if typically modest), and there just isn’t evidence that it confers any significant advantage." - http://cancergrace.org/topic/alimta-vs-alimta-and-avastin#post-1245808

JimC
Forum moderator

The general idea of giving maintenance therapy is to give the least intensive treatment that will keep the cancer from progressing. As Jim noted, the standard dose is 500 mg/m2 IV every 3 weeks, but it's not uncommon to modify this if patients need extra time (switching from every 3 to every 4 weeks is a rather frequent variation), and it would also be reasonable to stay on an every 3 week schedule but drop the dose by about 20% to keep it from being too intensive. If blood counts were on the low side, dropping the dose a bit would be very appropriate.

Good luck.

-Dr. West