My wife was diagnosed in October with NSCLC (adenocarcinoma) with mets to one adrenal gland and several lymph nodes. Her first line therapy was carboplatin plus pemetrexed, and her tumor shrunk by 20% by late January. A biopsy showed her to be positive for the 858R mutation on exon 21, and she was put on Tarceva as second line therapy. By March her tumor shrunk by 50% compared to pretreatment level. Unfortunately, her next scan in May showed progression. A second biopsy was taken that showed her to be negative for 780M, PD-1, PD-1L and Kras. Pemetrexed plus Avastin were administered in July as third line therapy causing severe side effects and no control in a scan done in August. The August scan showed massive progression and involvement of the second adrenal gland. Her sysmpoms include coughing up blood, severe fatigue and chest and back pain. For her fourth line therapy the oncologist is considering radiation, chemo other than pemetrexed/Avastin, immunotherapy and a possible clinical trial. Each of these alternatives in my view has negatives. Radiation is not systemic and won't stop further metastasis. The prior two courses of chemo were marginally effective or not effective at all. Immunotherapy is only effective in 15 - 20% of patients and probably less so being negative for PD-1 and PD-1L. I am concerned that if we pursue a clinical trial ,she may turn out to be ineligible or the start of treatment may be too far in the future. I fear that based on symptoms and degree of progression, this may be her last line of therapy.
Could you please comment on each of the possible treatment options in light of prior treatments, lack of gene mutation and proteins and her overall present condition.
Thank you in advance.
Treatment Options for Late Stage NSCLC - 1288369
afi203
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Reply # - August 20, 2016, 01:51 PM
You said she has a gene
You said she has a gene mutation, EGFR L858, is this correct? There is a second line TKI after Tarceva for this mutation, afatinib. Has this been suggested? They're also finding with immunotherapy that it hasn't worked well for those with EGFR mutations. This is just from reading that I've done and I'm sure someone here may have more info on that. Also there is a clinical trial for that specific mutation that you could check out. Not knowing where you're located, you'll have to check the locations in the trial yourself. Good luck no matter what treatment comes next. Take care, Judy
https://clinicaltrials.gov/ct2/show/NCT02349633?term=NSCLC+and+L858+mut…
P.S. I am not a medical professional but a two time lung cancer survivor and advocate.
Reply # - August 21, 2016, 08:25 AM
Thank you Judy. You certainly
Thank you Judy. You certainly are a very active advocate with postings on both Team Inspire and Cancergrace. I did mention afatinib to the oncologist, an he said that he didn't think it would work. I'll ask again..
Reply # - August 21, 2016, 08:50 AM
Hi afi203,
Hi afi203,
Welcome to GRACE. The evidence for the efficacy of afatinib in EGFR positive patients who have progressed on Tarceva is really not too impressive. The combination of afatinib and cetuximab seems to work better, but it is a difficult regimen to tolerate, with very significant skin issues and diarrhea. As Dr. Pennell stated:
"In 2014 the single completed trial of this combination was published in Cancer Discovery “Dual Inhibition of EGFR with Afatinib and Cetuximab in Kinase Inhibitor-Resistant EGFR-Mutant Lung Cancer with and without T790M Mutations”, which included 126 patients with EGFR mutant lung cancer who had progressed on prior Tarceva or Iressa. The response rate was about 30%, and was about the same whether patients’ tumors had the acquired resistance mutation T790M or not. The average duration of response was about 6 months, and there was no mention in the paper of how active this combination was for brain metastases. The skin rash and diarrhea with this combination were generally more severe than with Tarceva or Iressa alone." - http://cancergrace.org/topic/afatinibcetuximab-to-combat-acquired-resis…
Dr. West's original post on this combination can be found here.
Perhaps this regimen is something to discuss with your wife's oncologist.
JimC
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