History:
Stage 4 age 39 March 2011 (very advanced stage 4b). 1) Alimta/carbo + radiation. 2) Erlotinib 3) Carbo/alimta again. 5) GK to brain and FOUND ALK 2013 7) Xalkori 6 months 8) Alectinib trial 3.3 years 9) More GK and about to start Lorlatinib
Current Issue:
We are now about to start Lorlatinib for simultaneous progression to brain and chest. Had GK to over 20 brain mets last week due to symptoms. Rapidly and aggressive advancing disease(always has had). Always had bulky disease in chest with little leeway for progressive disease.
Question:
If Lorlatinib is unsuccessful with limited time to make decisions what would be your next steps?
He has not had Ceretinib (is there any point to this?) ...
If we can biopsy what you test for? Only ALK related or others?
If we can't biopsy what salvage would be best chance walking blind... chemo or immunotherapy?
Thanks
Jo
(Australia)
Reply # - February 12, 2017, 09:44 AM
Hi Jo,
Hi Jo,
Welcome to GRACE. I'm sorry to hear of the new progression after so many years of treatment. At this point, there really isn't a clear treatment path after lorlatinib. Dr. West has previously written that: “There also isn’t any real evidence yet that other second generation ALK inhibitors work after Zykadia [ceritinib].” – http://cancergrace.org/lung/2014/04/30/new-approval-for-zykadia-ldk378c… And in another post, he stated that he hadn't used lorlatinib (as of January 2016) since it was still an investigational agent. In light of this statement, it may just be too early to know whether one of these agents is likely to be effective after use of the other, and which sequence would be preferred. Of course, if options are limited, it might be worth a try.
Standard chemo would certainly be a leading option, especially since he hasn't had it for quite a while, and the only non-platinum agent was Alimta. Docetaxel (Taxotere) is approved here in the U.S. as a second- and later-line agent, and Taxol, Abraxane, Gemzar and other agents also have activity against NSCLC. Immunotherapy is a possibility, keeping in mind 1) only about twenty percent of patients respond well to it, and 2) in comparison to chemo it can take longer for immunotherapy to show results, which can be an issue if there is rapidly progressing disease.
You can test for a broad range of mutations, but the only ones which currently have practical value are those for which there are targeted agents. With that in mind, the patient and oncologist may want to identify a particular agent under consideration (perhaps one being tested in an available clinical trial) and test for the appropriate mutation.
I hope that lorlatinib is effective for an extended period, allowing time for more information to develop and new agents to appear.
JimC
Forum moderator