No more stable - 1262948

Hi Paulina,

Welcome to GRACE. I'm sorry to hear of your recent progression, but I think the fact that your cancer was stable for five years is a very good sign that it will respond to further treatment. Traditionally, oncologists did not return to a chemo drug that was used previously, but that thinking is changing. Since you stopped Alimta not because of progression but in order to have a treatment break, there is every reason to believe that it was keeping your cancer under control and can do so again at this point.

As far as whether to use a platinum agent with Alimta, this is not the general practice although in an unusual situation such as yours, it could be considered. The platinum drugs compromise bone marrow function and for that reason are usually not repeated, but there has been such a long interval since you had any chemo, the risk may not be as great.

As Dr. Pennell wrote:

"Although traditionally oncologists did not “go back” to drugs that have already been used, I would say that attitude is becoming less common with modern agents. I feel very comfortable re-challenging someone with a chemotherapy agent if that drug was stopped for a reason other than progression. For example, if someone has significant fatigue on Alimta after many cycles and wants a break, I would have no problem restarting it again if the cancer progressed many months later. If I was convinced that the cancer had become resistant to that drug, however, it would be rare to try using it again. We will sometimes reuse a chemotherapy drug if it has been a long time since it was used, usually more than a year." - http://cancergrace.org/topic/progression-on-gemzar#post-1260439

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In that same thread, Dr. West added:

"In the absence of convincing, clinically significant evidence of progression on the agent in question, I am reluctant to discard a treatment too early, at least one of the handful of agents that can be administered for a prolonged period without too many cumulative side effects, and Alimta (pemetrexed) is one of those.

I also agree that a platinum doublet is a tempting idea in someone who hasn’t had a platinum before, though the cumulative bone marrow suppression from having been on chemo for years may make it challenging or even infeasible to deliver a doublet years into systemic therapy."

The fact that you had a platinum drug previously, and quite a bit of chemo over the years, makes adding it to the Alimta less tempting.

Good luck with your treatment.

JimC
Forum moderator

As Jim noted, we tend to favor treatment out to 4-6 cycles of a platinum-based doublet as a clear point of diminishing returns. However, in patients who didn't actually progress on the prior regimen, it is arguable to consider doing back to the doublet, while bearing in mind that there is a cumulative risk of hypersensitivity reaction with ongoing platinum-based chemo, especially carboplatin, while cisplatin poses a particular risk for cumulative kidney damage and/or neuropathy.

The general principle I follow is that if we can't feasibly be treating for cure, I favor the least toxic approach to control the cancer over the next significant chunk of time (say, several months). If the cancer is indolent enough, the least toxic approach may just be ongoing surveillance with a plan to intervene when it looks more like there's an actual risk of cancer-related symptoms in the near future, as opposed to giving potentially side-effect inducing chemo that may well be worse than the underlying disease. If the cancer progression is significant enough to justify treatment, I favor the least toxic approach to do the job: if a single agent approach can feasibly do the job of controlling/shrinking the cancer (including consideration of a previously administered agent if there wasn't prior progression through that treatment), then I favor a single agent over a doublet. If it's more likely a doublet will be required, then a doublet is reasonable, though we'd prefer to use the least challenging doublet to do the job.

Good luck.

-Dr. West

Sorry, that's a little too specific. I don't know of any clinical research with that level of granularity and suspect there isn't any.

Good luck.

-Dr. West

Papillary adeno seems to be considered a rare subtype of BAC. It's very possible for a cancer to change histologic chem while being quiet for 5 years, basically trying to find it's way back. It's also possible that it was papillary in the first place. You'd need to speak to your oncologist about the significance for you but since it's so rare there isn't a standard of care for it beyond standard of care for nsclc. I did some poking around and found this from PubMed published in 1997 (a long time in nsclc these days), "There continues to be confusion as to whether papillary adenocarcinoma (PA) of the lung is a specific histologic entity or simply a variant of bronchioloalveolar carcinoma (BAC). http://www.ncbi.nlm.nih.gov/pubmed/8990140 and from the same site but 2005, " progression markers and tumor suppressor products found that PA (papillary adeno) seemed a more advanced adenocarcinoma than BAC, but no differences were observed among PA subtypes." http://www.ncbi.nlm.nih.gov/pubmed/16185291

I hope you understand if your chemo regimen of taxol/carb is too tough an easier one can be used. Your doc prob wants to knock it down hard with the first treatment and that combo has shown to be the one.

I hope you are pleasantly surprised at how easy the chemo is on you. Read up on staying ahead of chemo side effects it can make a huge difference.
Keep us posted,
Janine

I agree with Janine. It's not rare for me to see BAC characterized as papillary adenocarcinoma, and I would not presume that they are a different process. That's certainly possible, as a lung cancer can have different areas that appear as one subtype vs. another, but I think there's a very significant chance it's the same process being called two different things.

Good luck.

-Dr. West

Hi Paulina,

I am sorry to hear of the progression of your cancer. It is not unusual for a BAC cancer (which may be the same process as what is being called papillary adenocarcinoma, as Dr. West said earlier in this thread) to cause a mucus-producing cough. Usually the best way to reduce that cough is by successfully treating the underlying cancer. Over the counter medicines such as Mucinex may help reduce the symptoms.

Since there has been a long interval since your earlier treatment with Alimta, I think it is perfectly reasonable to return to it now. Taxotere may also be an option, since there have been studies which have indicated that it can be effective even after Taxol. There may be other agents available in clinical trials in your area, and lung cancer research has been producing new therapies at an increasingly rapid pace. Certainly not time to give up!

Good luck with Alimta.

JimC
Forum moderator

What wonderful news Paulina! I hope you do very well moving forward in making your cancer a chronic issue instead of a terminal one. Don't forget chemo breaks are always on the table while you do so well.

Congrats,
Janine

Good outlook Paulina and very reachable. I honored to know you and the tough decisions you've made.