Just diagnosed with stage 4 NSCLC with bone mets. What treatment should I start? - 1293968

Hi Irina,

Welcome to GRACE. I am sorry to hear of your diagnosis, and I hope we can help you with the questions you have.

It's natural to want to start treatment as quickly as possible, but unless you have rapidly progressing disease (as determined by worsening symptoms or changes on scans), it is best to wait until you have the results from the brain MRI and genetic testing.

We certainly hope the MRI will show no evidence of disease, but if there is then your oncologist may want to start with radiation to treat any brain metastases before continuing with systemic (full-body) treatment such as chemotherapy, targeted therapy or immunotherapy. Aside from its use in treating brain mets, in stage IV disease radiation tends only to be used to relieve symptoms or prevent bone fractures.

If testing reveals a genetic mutation or alteration, such as EGFR or ALK, for which there is a targeted therapy available, then that would usually be the preferred initial therapy. If instead there is high PD-L1 expression, then immunotherapy may be considered, although the response rate tends to be significantly lower than that of the targeted therapies used for genetic mutations, so your oncologist may prefer to begin with standard chemotherapy.

Please let us know if you have further questions.

JimC
Forum moderator

Hi Irina,

Initial treatment with standard chemotherapy is most effective when a combination of a platinum agent (carboplatin or cisplatin) and another agent is used. Targeted therapy and immunotherapy are usually single-agent, although clinical trials have been testing combinations of immunotherapy agents with some promising results.

JimC
Forum moderator

Hi Irina,

As far as starting with immunotherapy, that is an option that can be discussed with your oncologist. One factor which leads some patients to choose chemotherapy first is that it takes a bit longer for immunotherapy to show results, while if chemo is effective it tends to show results pretty quickly (usually on a scan four to six weeks after starting it and/or a marked improvement in symptoms). But if your cancer isn't progressing rapidly and you aren't experiencing significantly worsening symptoms, then the delay is acceptable. Plus, if you start with immunotherapy and it isn't effective, you can switch to chemo.

There are various agents used in combination with platinum. Alimta (pemetrexed) is a popular choice because most patients tolerate it very well, and it doesn't tend to cause hair loss. Other choices include Taxol (paclitaxel), Abraxane, gemcitabene (Gemzar) and vinorelbine (Navelbine).

JimC
Forum moderator

Hi Irina,

Welcome to Grace. I’m so sorry about your diagnosis. Yes you’re right, if a targetable mutation is found such as EGFR, ALK or ROS1 a targetable drug is the 1st line drug of choice. Though rare a high PD-L1 expression is found along with a targetable mutation, in that case the targetable drug is still the 1st line choice.

However if there is no targetable mutation but a high PD-L1 is found then most oncologist prefer to start with an immunotherapy since some have been proven to provide longer lasting efficacy and standard chemo and normally with fewer side effects. One reason to start with chemo instead of immunotherapy is if you need a quick result now then chemo is more likely to give quicker results.

If there are neither high expression of PD-L1 or targetable mutation then chemotherapy is used as 1st
line. Carboplatin instead of cisplatin is most often used for those with stage IV disease. There is no absolute data stating cisplatin is better but it does definitely cause more side effects. Alimta is most often the second drug in this combo. Alimta has fewer side effects and at least as good as the taxanes. So the combo of choice is usually Carboplatin with Alimta for 4 to 6 cycles followed by a break or continuing with alimta alone.

There are also some promising trials for other mutations that may be appropriate for 1st line. Jim mentioned also combinations of immunotherapies being tested that are showing lots of promise. If you think you might be interested in any of these then it's important to review your options with you oncologist before starting first line therapy or any next line of therapy. With that in mind. If your oncologist isn't a lung specialist at a large teaching/research center it might be a good idea to get a second opinion during your "transition" times (before making changes in treatment).

I hope this is helpful.
All best,
Janine

Re 2nd opinion. Cancer treatment has become and continues to be more complicated each day and each type of cancer has it's own set of rules and subsets. For this reason many people including medical oncologist who treat many types of cancer find it helpful to get a 2nd opinion at transition times. I don't want you to think you should get a second opinion but if there are questions about the direction you should take it can be very helpful.
The following link is perennial favorite of mine. http://cancergrace.org/cancer-101/2011/11/13/an-insiders-guide-to-the-s…

Hi Irina,

I'm sorry that the biopsy did not go well. The question of whether to wait for additional testing before choosing an initial treatment plan is a difficult one for many patients, who quite understandably are anxious to start their cancer treatment as soon as possible. There isn't a clearly right or wrong answer. As a practical matter, though, once a lung cancer is stage IV, a delay of a few weeks is usually only significant if there is evidence of rapidly progressing disease. And if a finding of high PD-L1 expression leads to the choice of immunotherapy and that therapy is effective, then you will have avoided the usually more troublesome side effects of chemotherapy.

JimC
Forum moderator

Hi Irina,

Starting with standard chemotherapy with a plan to switch to immunotherapy if necessary is a perfectly reasonable course of action which many patients choose to follow. And though PD-L1 expression can change for a small subset of patients, such a change is not typical.

The combination of a platinum agent such as cisplatin or carboplatin plus Alimta and Avastin is a very popular and effective regimen. Alimta tends to be one of the best tolerated chemotherapy drugs available, and for most patients Avastin is also. There is a never-ending debate among oncologists over the question of cisplatin vs. carboplatin. There is evidence that cisplatin is a bit more effective than carboplatin, but it can come at a cost, as cisplatin is often more difficult to tolerate (although you can find patients who sail through cisplatin and others who struggle with carboplatin). Many oncologists feel that in the stage IV setting any added benefit conferred by cisplatin is not worth the additional toxicity, since a chemotherapy regimen that you are able to finish as scheduled is better than one that you quit due to side effects. Dr. West discusses the two drugs here.

JimC
Forum moderator