stephen
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My wife is on a off-licence Keytruda (PD1), Avastin, Capecitabine combination for advanced Triple Negative breast cancer. She has received the 2nd cycle last week. Multiple mets in lungs, bones, brachial plexus and brain.
My question relates to her worsening symptoms of breathlessness and cough, which is also not being controlled by palliative medication (she will very soon have scans to check for pulmonary embolism and pneumonitis). In some cases pseudoprogression can happen on PD1's - if this was happening in the lung tumours would you expect symptoms like breathlessness and cough to stay the same, get worse, or get better?
Many thanks.
Forums
Reply # - May 28, 2015, 08:46 AM
The is an answer from Dr.
The is an answer from Dr. West to a very similar question,
"First, it’s worth noting that pseudoprogression is possible but not common (<10% of patients). Most of the time, when things look worse on scans, it’s because the cancer is progressing. However, sometimes with immunotherapies, one or more lesions is actually bigger because host (patient) immune cells (T cells) are attacking the tumor cells. So while there are more cells, it’s not actually more tumor.
While I suppose it’s theoretically possible for the influx of host immune cells to cause local problems, I’ve never heard of that. Immune cells probably wouldn’t have the same tendency to invade or displace normal tissues that tumor cells will. Pseudoprogression has really been described in the setting of patients feeling and doing better, but the scan appears inexplicably worse.
You can read more here:
http://oncology.jamanetwork.com/article.aspx?articleid=2174768 " http://cancergrace.org/topic/pseudoprogression-on-immunotherapy
There's a good representation of what's described here on the original link.
I'm so very sorry your wife is in such bad shape and hope hope she gets her pain under control asap.
Janine
Reply # - May 28, 2015, 04:54 PM
"Pseudoprogression has really
"Pseudoprogression has really been described in the setting of patients feeling and doing better, but the scan appears inexplicably worse." To me, this is key. If pain, fatigue, and other cancer symptoms are getting worse, then we need to think twice before continuing on the same treatment. In my experience, patients are often reluctant to discontinue PD1 in the face of worsening disease, but we have to be realistic.
Reply # - May 28, 2015, 11:51 PM
Thank you for the replies Dr
Thank you for the replies Dr Creelan, and Janine. My follow-on question is now how long should my wife (assuming she is well enough for treatment) stay on the PD1 + combination to give it the maximum chance of working? I have seen graphs on the GRACE site that appear to show some responses only fully happening around the 40-50 week period. For information, we are paying for this treatment privately so we are luckily not restricted by health insurance policy or clinical trial protocol. I have also seen some case studies online where the PD1 was stopped because of assumed progression, but on re-biopsy the tumor was dead. After how many months/weeks could we safely assume there would be no response (i.e. from previous experience when can 100% of responders be identified)?. Many thanks.
Reply # - May 29, 2015, 06:39 AM
Hi Stephen,
Hi Stephen,
If you're referring to the chart at http://cancergrace.org/cancer-treatments/2014/12/30/how-is-immunotherap… it tends to show that within about 20 weeks (with a couple of exceptions) at least stability has been achieved, and the timeline for actual shrinkage varies by patient. Although there is no specific duration of treatment after which you could assume non-response, if after 20-30 weeks your wife is feeling worse and scans show progression, then it might be assumed it's not going to be effective. But that will be a judgment call to make in consultation with her oncologist, perhaps based on the rate of progression and availability of other options..
I hope that you see evidence of response soon.
JimC
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