SCLC and liver mass recurrence - Treatment options, targeted therapies ? - 1270558

marich1
Posts:3

I have reviewed your excellent information for my friend with recurrent Liver met assoc with SCLC =post Carboplatin + Etoposide full course (excellent response), followed by CRI with followup scan May showing large, diffuse liver mass, recently followed with 2 more courses Carbo+Etoposide; and followup scan shows NO CHANGE in liver mass - good/bad news. The oncologist is going for 2 more rounds of same chemo then scan; blood work too bad for treatment this week. I went with appt last week & he is says genomic testing does NOT inform treatment options for SCLC - but asked him about the novo + illuuimob trials, mentioned Roy Herbst discussing and he only said... was that for SCLC. A Doc there suggested (on the side) Foundation One and I contacted them& have have info on other groups previously. This is the future (- I loved Tom Browns recent interview with Jeffrey Bland- Father functional Medicine). Foundation one has published data on SCLC mutations - showing RICTOR in top 7- so many with SCLC former smokers; but mTORC1/2 targets are options. then PD1+ SCLC benefited with Keytruda; Checkmate 032 with SCLC had 33% RR with NIVO + illumimob and 15% NIVO alone. while Keynote 028 for pretreated PDL1+ had 35% RR with Keytruda for 6mo+; but true that only 28% were PLL1+. SO.... where can my friend go for 2nd opinion- Tom Brown is expert on liver but Swedish Inst does not seem to be anything out of ordinary DR. West. I valued comments by Dr. Ghandhi at Dana Farbe in your recent interview. Really appreciate your input.. Thanks so much - mary ann richardson, DrPH, MPH.

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Reply # - July 22, 2015, 04:02 PM

Dr West
Posts: 4735

While we're all hopeful about next generation sequencing for identifying potentially relevant molecular markers for many cancers, at this time there just aren't any targets in SCLC that are useful in clinical practice. Regardless of what proponents who sell molecular testing say, it is clearly not recommended and has no known value in SCLC, at least not yet. This isn't to say it isn't an important, interesting research question, but it doesn't have a role yet outside of that.

As for immunotherapy, there is some promise to immunotherapy in all sorts of settings, including small cell lung cancer. Importantly, however, if you heard Leena Gandhi speak, she also mentioned how challenging bordering on infeasible it was to do PD-L1-based testing of current tissue in relapsed SCLC -- MANY if not most patients were too sick to get treated on the trial by the time results came back. And that 35% response rate is really 7 patients out of 20, very small numbers, out of more than 100 who started out trying to get on the trial. That's clearly a major problem, and we cannot say that immunotherapy should be a treatment for SCLC outside of a trial setting.

If your friend is especially motivated, I would say that the best option might be to pursue a second opinion from one of the centers that has led immunotherapy trials and may have one or more in small cell. These centers would be places like Dana Farber, Yale, Memorial Sloan-Kettering, Johns Hopkins, Moffitt Cancer Center, MD Anderson, perhaps UCLA. There are potentially other centers in her area that have trials of immunotherapy in SCLC, but it is almost certain this line of treatment, which costs $10,000 per month, wouldn't be covered outside of a clinical trial setting.

Good luck.

-Dr. West

Reply # - July 24, 2015, 06:17 AM

marich1
Posts: 3

Thank you Dr. West - hopefully the field will be evolving quickly. She has access to one of these top centers and I will pass along your comments; However, when I spoke with their trials group a few weeks ago the clinical trials nurse said immuno-therapies are "not a cake walk either" and the NIVO trial was under amendment but not enrolling for the SCLC arm. thanks again for your input.

Reply # - July 24, 2015, 07:46 AM

marich1
Posts: 3

Dr. West - one more thought.

the SCLC liver met , originally thought to be resolved totally with 6 courses (i believe that #) of carboplatin + etoposide , grew rapidly during the course of XRT that immediately followed that chemo; and this diffuse liver mass has not regressed after 2 additional courses of carboplatin + etoposide - but has not grown either. Would you think liver mass is now a different, mutated form of SCLC from the original mass - ? Or could it just need more time? Time is not on her side -- blood counts too low for a 3rd round last week. thank you again for your thoughts.

Reply # - July 24, 2015, 12:37 PM

catdander
Posts:

Hi Mary,

The conclusion would be that the 2 extra courses of treatment caused the liver met to stay as it was. There just isn't any data to show that mutations have developed, not that it isn't so plus there aren't actionable mutations in sclc outside of trials.

SCLC normally responds very well to first line treatment because chemo attacks dividing cells and SCLC is a fast moving disease. Unfortunately a chemo regime becomes less responsive over time.

A 2nd line of treatment is the standard of care. Care for sclc hasn't changed in many years so standards 10 years ago are still the same.

This is a horribly unfunded and difficult cancer. We need so much more research in this area.

I hope your friend finds a plan that works well.

Sincerely,
Janine

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