Dear forum,
Father-in-law was diagnosed with squamous lung cancer. It was described as stage IIIB and we were told that he had a 30% chance for cure by chemo+radiation. A week later we were told by the oncologist that they took a closer look at the CT scans and chemo+radiation is a no go. Instead the idea is to treat him using chemo only (with a non-curative intent as I understand). The explanation is that although it is a IIIB, there is a mass both at the bottom and at the top of the lung, and there are nodes on both sides of the chest, and also one node above the collarbone. Because of that, radiation is not an option (we're told).
The oncologist also said that he can try to classify the disease as stage IV, which would make dad eligible for a clinical trial.
So, now dad is trying to get into a clinical trial of Avelumab vs chemo. He signed a consent form and an FFPE block was sent for PD-L1 testing (three days ago). To get Avelumab as a treatment, PD-L1 needs to be positive ("high expression") and father needs to draw the arm with Avelumab, with 3/5 chance.
There is also another trial, in another hospital, also for PD-L1 positive NSCLC, that compares pembrolizumab + epacadostat to pembrolizumab + placebo. The problems with that trial are that it is another hospital, which will visit for the first time this week, so it's a big unknown as to whether he'd be eligible and how long would treatment get delayed by this - the description says that "recruiting is planned to be opened in December". That sounds like at least a month of waiting for me. On the other hand, we don't have pembrolizumab in Poland at all, and I only saw first line trials with pembrolizumab...
Apologies for the long post, all of this is really difficult.
*Is it possible that a different hospital would want to apply curative chemo+radiation?
*What is the standard of care for squamous IIIB/IV that is not treatable with curative chemo+radiation?
*What do you think about the Avelumab trial?
Reply # - November 12, 2017, 03:02 PM
Hi Bolu and welcome to Grace.
Hi Bolu and welcome to Grace. I'm so sorry to know about your father-in-law. According to the US's National Cancer Institute cancer that is found in nodes on the opposite side from the primary tumor is staged IIIB because the cancer cells have to move through the lymph or blood system to get there. Once cancer is found to be in the lymph or blood system it's considered locally advanced. With the several spots that you've described radiation could destroy too much lung tissue.
Clinical trials can be an excellent way to get new treatments that aren't available otherwise and immunotherapies are very promising. Clinical trials also provide excellent care and wouldn't take someone who is too sick to have a chance of benefit.
Getting a second opinion is a good idea if someone is not confident about options or staging given. While waiting may seem a dangerous move for those with stage IV nsclc it most likely won't hurt as long as symptoms are in check. Symptoms like unmanaged pain or tumor that's causing problems may need treatment sooner than later.
I hope your father-in-law does well and know we're here when you have questions. We also have an excellent library of informative posts and videos best found by our search engine or Jim can help you find what you're looking for.
All best,
Janine
Reply # - November 12, 2017, 03:25 PM
Hi bolu,
Hi bolu,
Stage IIIB lung cancer tends to be the most difficult and controversial stage for which to decide on treatment. In general, chemo/radiation is the typical treatment, but it's important to stress that the particular circumstances of a specific patient's cancer may dictate a deviation from the norm. Dr. Pinder discusses treatment for Stage IIIB lung cancer here. From what you've written, it's not clear why your father-in-law's doctor feels radiation is inappropriate in his case.
Also, from your description of the locations of the cancer, this is not clearly Stage IV, which involves spread of the cancer to distant sites. Lung cancer confined to the chest is considered locally advanced.
Since Stage IIIB does not always have a clear-cut standard of care, obtaining a second opinion may be a very good idea. Having another pair of eyes review the information can either lead to a different treatment plan or confirm the current recommendation. Either way, you're likely to learn more about the cancer and the treatment options.
Still early in the clinical trial process, there is some information on Avelumab here:
http://cancergrace.org/lung/2017/03/07/more-immunotherapy-agents-are-in…
JimC
Forum moderator
Reply # - November 13, 2017, 06:24 AM
Thank you very much for the
Thank you very much for the replies, Janine & Jim.
We are going to another oncologist for a second opinion this week.
If it turned out that systemic, non-curative treatment is the only option, what would be the standard of care? Should PD-L1 be tested and if positive, Keytruda/pembrolizumab given? Should EGFR, ALK be tested or they don't make sense for squamous?
I'm asking about standard of care treatments because we have limited options here in Poland, and oncologists only prescribe what they can prescribe, while I would still like to know what might happen if we lived in, say, the US. For instance, there is no pembrolizumab for NSCLC in Poland. Only clinical trials. We may still be able to get pembrolizumab or something else through a clinical trial somewhere else in Poland.
Reply # - November 13, 2017, 07:36 AM
Hi bolu,
Hi bolu,
Although the percentage of EGFR+ and ALK+ activating mutations is low in patients with squamous lung cancer, many oncologists will order genetic testing for all their patients. We just posted this podcast in which Dr. Weiss discusses EGFR-based treatment for squamous patients.
Standard of care for systemic-only treatment is still chemotherapy or, if activating mutations such as EGFR or ALK are present, targeted therapy. Where PD-L1 expression is high, some oncologists and clinical trials are using immunotherapy as first-line treatment, but until we have a better understanding of which patients are most likely to do well, response rates are lower than we would like. For patients with high expression and minimal symptoms or evidence of rapid growth, first-line immunotherapy is not a bad option, since chemotherapy can be used if the immunotherapy is not effective.
JimC
Forum moderator
Reply # - November 13, 2017, 10:47 AM
Bolu,
Bolu,
I've edited my response above. I originally stated N3 (node involvement on the opposite side of the chest) involvement was considered stage IV. I misspoke. Spread outside the chest wall is considered metastatic. If cancer cells made there way into the lymph system and across the the chest to the opposite side it's assumed cancer cells are circulating through the rest of the body and treatment is likely unable to reign the cancer back in, kind of like the barn door opening that let the horses out, closing the door won't bring them back inside.
On occasion aggressive treatment will work but too often it just makes someone very sick and unable to withstand treatment that would otherwise help with quality of life and longevity. As Jim said stage III is the most difficult and controversial to treat. Sometimes oncology is said to be as much art as science. It's times like this that make that statement so evident. There is much to take into consideration. I'm glad your father-in-law is getting a second opinion, a second pair eyes usually adds to the perspective of such an individual situation.
Best of luck,
Janine