Hi, I'm posting this on behalf of my 60 year old mother who was diagnosed with Stage IV adenocarcinoma back in February. She's Asian and has tested positive for EFGR mutation.
She recently completed her first round of of chemo, which lasted 4 months (Paraplatin + Gemzar). She responded exceptionally well. During the last month of her chemo, she also completed 6 weeks of radiation to the chest (radiochemotherapy) because her doctors felt it would benefit her survival in the long term.
After a month break, she's about to start on her second round of chemotherapy but her oncologist said it was also up to her if she wanted to switch to Tarceva. He gave us no opinion either way as to which would be the better course of action for her overall long term survival. She has been handling the chemo treatments fine with no ill effects, except a little fatigue.
I know there's no right or wrong answer as to which way to go, but I was just wondering what the latest data says about when is the right time to switch that would best benefit patients in the long term.
It's a tough decision so wanted to get different perspectives from everyone. Thanks in advance!
Reply # - November 22, 2015, 07:47 AM
Hi sidekick4mom,
Hi sidekick4mom,
Welcome to GRACE, and congratulations to your mom on her good response to chemo. Happy to hear that she's tolerated it so well. Since everyone's situation is a bit different, there isn't really specific data to provide a clear cut choice.
One matter that is pretty well settled is that long-term use of a platinum agent can cause cumulative side effects as well as damage to bone marrow function. That can make it more difficult for a patient to tolerate subsequent treatment regimens. After the initial 4-6 cycles of successful, well-tolerated first line treatment, if maintenance therapy is chosen it is only the non-platinum agent that is continued.
On the other hand, when an activating EGFR mutation is discovered, the general thought is that an EGFR inhibitor would be the leading choice for first-line treatment, or that it be used after first-line chemo. Most patients find it relatively tolerable, although skin toxicities and diarrhea can be troublesome, at times to the point of requiring treatment breaks, dose reductions or discontinuation.
Depending on her current situation (you haven't specified how much cancer is left, and where it is), another option would be to take a treatment break and keep a close eye on her cancer through follow-up scans, only re-initiating treatment when clinically significant progression occurs. Although this sounds scary, the idea is that the battle with cancer, in Dr. West's words, is a long-distance race rather than a sprint. The goal is to use the available treatments so as to get the maximum benefit from each, while providing the best quality of life for the patient.
Sending good thoughts to you and your mom. Please let us know if you have further questions.
JimC
Forum moderator
Reply # - November 22, 2015, 03:36 PM
There's no 'right answer'.
There's no 'right answer'. The EGFR TKI does have side effects, especially long-term chronic effects like fatigue. I would prefer to delay starting if the existing cancer has responded well to chemotherapy with radiation. Also starting the EGFR TKI soon after wide field chest radiation could increase her risk for radiation pneumonitis.
Personally I would favor completing 4 total cycles of chemotherapy, and then waiting until there is any new or enlarging disease before starting the EGFR TKI. However, there are a lot of nuances to this decision, and it really depends on individual factors, clinical judgment and patient preference.
Reply # - November 22, 2015, 10:48 PM
Thanks for your insights JimC
Thanks for your insights JimC and Dr. Creelan. Since you both recommend taking a break from treatment if the cancer is held at bay, how often do you recommend she get scanned to check if there is any clinically significant progression? Obviously we want to keep a close eye on her condition, but do it in a manner that's safe.
Reply # - November 23, 2015, 07:54 AM
A two to three month interval
A two to three month interval is fairly common, but it's a judgment call by your oncologist without a right or wrong answer. As Dr. Weiss has said:
"The appropriate interval varies by patient situation, but typically ranges from 6 weeks to several months. Lack of more frequent scanning isn't so much a safety concern as lack of reason--cancer takes time to shrink or grow and so scanning more often doesn't help with making treatment decisions." - http://cancergrace.org/forums/index.php?topic=4962.msg30272#msg30272
JimC
Forum moderator