Conventional RT or SBRT (CyberKnife) - 1294230

My understanding is that local control and survival is somewhat higher with SBRT and is considered now the standard of care but the main issue is that it is more convenient for the patient. It is also possible to re-irradiate with SBRT. This is an area that is currently under investigation by researchers. It is best to ask your doctors what they think but anyway here are some useful tidbits from the literature on re-irradiation in lung cancer.

"Salvage therapy with re-irradiation with SBRT technique for in-field recurrent lung tumors appears to be a effective and well-tolerated option for cautiously selected patients even centrally located. Our results suggest that, lower BED doses could still provide excellent LC for recurrent lung tumors in the previous RT field with an acceptable complication rate."

http://www.jto.org/article/S1556-0864(16)33268-3/fulltext

Also " Reirradiation (reRT) of thoracic malignancies may be an optimal strategy for providing definitive local control and offering a new chance of cure. Yet, retreatment with radiation therapy can be challenging for fear of excessive toxicities and the inability to safely deliver definitive (≥60 Gy) doses of reRT. However, with recent improvements in radiation delivery techniques and image-guidance, dose-escalation with reRT is possible and outcomes are encouraging. Here, we present a review of various radiation techniques, clinical outcomes and associated toxicities in patients with locoregionally recurrent NSCLC treated primarily with reRT."

http://jtd.amegroups.com/article/view/18319

Hi Lulu,

Welcome to GRACE. onthemark has provided you with some great information, and it alludes to the most important factor in the decision: the location of the spots to be radiated (or possibly re-radiated in the future). That determination is made on a case by case basis by a patient's radiation oncologist, so it would be good to get as much detailed input from your Dad's rad onc in order to make an informed decision.

In the meantime, congratulations on the good response to treatment, and good luck with future therapy.

JimC
Forum moderator

Hi lulu and welcome to Grace. I'm so sorry about your father's diagnosis. I may be missing something but radiation treatment for metastatic nsclc is usually reserved for the lungs only if it were causing some obstruction or if it were the only known cancer left. But since there is other known cancer radiation could cause more damage than good. That's a conversation for both the medical and radiation oncologist whether radiation is appropriate or not. The goal is to live long and as well as possible and you want to save as much healthy lung tissue as possible.

All best,
Janine

Hi Lulu,

I know exactly how you feel; most of us who have dealt with a cancer diagnosis, either our own or a loved one's, feel a helplessness that drives us to seek out the next option for fighting the disease. Quite understandably, we constantly want to be doing something to help eradicate the last vestiges of cancer.

But stage IV lung cancer usually doesn't work that way. When treatment results in significant shrinkage and stable disease, the best option may be...nothing. It's called watchful waiting, a period during which a doctor will closely monitor a patient with follow-up scans and physical examinations to check for indications that the cancer may be progressing. Watchful waiting can be a tough concept for both patients and their loved ones, but it does have significant advantages. The patient's body can recover from the rigors of treatment, and the patient can have some time in which life is a bit more "normal", without the constant roller coaster ride of therapy-induced side effects. And while most people tend to think that it's better to prevent progression than to address it when it happens, that's not what the clinical experience shows. As long as follow-up scans and physical exams are performed at relatively short intervals and new symptoms are reported promptly, progression can be addressed early.

Although there are more treatment options available to lung cancer patients than ever before, the number of those options is finite, so we like to get as much benefit from each of them as possible, and watchful waiting is one of the tools that can help achieve that goal. As Dr. West is fond of saying, treatment for stage IV disease should be a marathon, not a sprint.

It's at least worth discussing with your Dad and his oncologist.

JimC
Forum moderator

I'm not sure what the best answers might be because you have to have all the facts and treat the whole person, but this is probably a common question now amongst lung cancer patients and something I have thought about if my cancer were to return.

I would be skeptical of irradiating only one of the remaining active sites if it is not causing problems and appears to be controlled by maintenance therapy. I think this is pretty consistent with what Jim and Janine have posted and what Dr. West has written on dealing with stage 4 lung cancer.

I certainly wouldn't go for radiating lymph nodes if there is no apparent active disease there. If any of these conditions were to change then the therapeutic response would also. It is still the case that the target for stage 4 lung cancer is not a cure but of prolonging the time that the patient is relatively well. With multi-modal therapy including immunotherapy some patients are living a long time with this illness and may end up dying of other things. So there is hope. Just about every week in the news a new study about lung cancer comes out. They are starting to point the way to real improvement that has not been seen in lung cancer for decades. On the other hand, survival statistics still have a long way to go to catch up with other cancers, whose research has historically been better funded.

I think a big difference now is that global pharma is starting to see a huge commercial opportunity in lung cancer treatments that didn't exist before.

Hi Lulu,

You are really knowledgable about all the studies. I am not clear to what extent the immunotherapy drugs are available in China. I would inquire directly with oncologists where you are. You might be able to get into a trial or it might be an option for standard of care after chemo.

Hi Lulu,

Those are all good questions and I'd like to know the answers as well. (I might try later when I can think of some good search terms in scholar.google.com)

This would also be so helpful information to others in China or other countries who might be on the 'cusp' of receiving immunotherapy treatment as standard of care in line with the most recent studies.

I would still discuss all the options with one or two oncologists involved directly in your father's treatment. There is always the question of best medical judgement for the care of a particular individual rather than the generic statistical best odds.

I don't know if any studies have been done of Keytruda as maintenance therapy with or without chemo and with or without targetted radiation for oligometastacise (sp?) as well. It's a complicated question too because each drug has its own side effects which have impact of quality of life long term.

Hi Lulu,

The question of the relative value of maintenance therapy in general has been debated for a number of years, with no clear answer. It appears that the NCCN guideline regarding pemetrexed maintenance was downgraded a few years ago from category 2A to 2B (based on low-level data in either event), although the current guideline is unclear on that subject. It should be remembered that the guidelines describe therapies which are appropriate, based on either high- or low-level evidence, but in each situation there are a number of appropriate therapies. One of the options stated in the NCCN guideline for stable disease after first-line treatment is close observation (watchful waiting).

It's been difficult to determine the true value of maintenance therapy in clinical trials. An improvement in progression-free disease from maintenance therapy (which makes sense, since you're continuing to treat the disease and you would expect progression to occur at least somewhat later) doesn't necessarily translate to an improvement in overall survival, and patients in both of arms of such a trial often eventually receive the trial drug or other subsequent therapy, which clouds the picture. But there is one trial that showed an improvement in both PFS and OS, the PARAMOUNT trial, discussed by Dr. Socinski here. When the drug policy board (NICE) in Great Britain reviewed the evidence two years ago, this was still the only trial evidence available.

So either option is appropriate, and the choice involves both the art of oncology and the personal preferences of the patient.

JimC
Forum moderator

That sounds right Lulu, oligomets aren't usually in the liver. Liver mets are usually thought to be fully metastatic. At any rate it would need to be locally treated to expect it to be eradicated. There really isn't a known best choice for using maintenance treatment and many oncologists let the patient guide the choice to forgo maintenance or not. Some people feel safer not stopping treatment and others want the break. The most important thing to remember if a break is taken is to scan often 6-12 weeks and contact the onc with new or worsening symptoms. This way you catch the progression early to start treatment asap. This is an approach many oncs feel is just a good (or better since you get a break) than continuing with maintenance.

Your poodle looks comfy. Is it a pup? I have a redbone hound that gets that kind of comfy but I swear she sheds as much as my husky did. If she ever gets a dog it will be from the poodle family.

Hi Lulu,

"To live with a lot of uncertainty and fear is just not easy. But that’s what I need to learn with my Dad’s situation I guess."

This statement resonated with me and I would guess with many others who are facing similar life threatening situations either themselves or close family members. We want to do everything pro-actively possible and make some kinds of plans for the future. Watchful waiting is not the same thing as just waiting.

I would let go of your concern about missing out on the immunotherapy + chemo, clinical trial as first line therapy. No one knows what the outcome is going to be heading into a trial, so the evaluation of the information ex post facto is different than in real time.

I lost my thyroid function after one round in a clinical trial for a immunotherapy drug as adjuvant therapy and dropped out of the trial because I was concerned about what organ might be attacked next by the drug under consideration.

On the other hand once there is clear benefit that is tangible in real life, then the level of acceptable risk is higher. That is why most if not all new cancer drugs are first tested on metastatic patients.