Finished 4 carboplatin alimta avastin. What next? - 1294402

Hi Irina,

Welcome to GRACE and I'm sorry that you have to deal with lung cancer. I had trouble following part of your description. It seems like you already had a biopsy to be told you have poorly differentiated adenocarcinoma. Was there not enough of a sample to also check for mutations?

My guess is that the best advise would be to decide on a treatment plan after your May 21 PET scan and brain mri. At that point I would get a second opinion from another oncologist since you have doubts about the recommendation of your present one. It seems like surgery to get a biopsy for metastatic cancer after chemotherapy is a big step and one I would also be hesitant about. If you have one or only a few isolated hot spots on the PET scan then I think radiation makes sense. if nothing shows up active on the PET scan then you wouldn't need radiation at this point I.

My first thought is if it turns out you still have active metastatic disease, which you will know soon, it should be possible to biopsy one of the metastatic sites that would be less invasive than a lung surgery.

Hi Irina,

I think the first step is to see the results from your upcoming scans before making any decisions about future therapy. Those results will give you an idea about the efficacy of your fist=line chemotherapy. If you've had a good response, your doctor may suggest continuing with maintenance Alimta in an effort to keep the cancer under control for an extended period. Another option is "watchful waiting", which entails keeping a close eye on the cancer through follow-up scans and clinical evaluations, and restarting treatment if progression is seen. Some patients find that a difficult concept to accept, but with Stage IV lung cancer it is often impossible to eliminate all traces of the cancer, so stable disease is considering a good result and may last quite a while. There's a lot to be said for enjoying a treatment break, free from the side effects of therapy.

Without all the information available to your doctor, it would be difficult for us to evaluate the risks and benefits of an open biopsy - we don't know why it was difficult to obtain sufficient tissue for mutation/PD-L1 expression testing. One observation is that it can be difficult to biopsy bone metastases, so it is probably not a viable option to obtain a biopsy from them. You state that your chance of having an actionable mutation is low. If that is because you have a significant smoking history, then mutation testing is not as likely to reveal an activating mutation, a factor that may influence your biopsy decision.

If your bone mets are causing pain or threatening to cause fractures, then radiation may be used to palliate symptoms and/or protect the bones. Many patients with EGFR or other mutations take a break from treatment for palliative radiation to bone mets, then resume the EGFR inhibitor without a problem. You needn't worry about the radiation altering the mutational status.

[continued in the next post]

[continued from the previous post]

Although your insurance doesn't require high PD-L1 expression prior to Keytruda use, the evidence shows that the response rate is significantly better for patients who have high expression.

I wish there were a simple answer to your questions, but as is often the case with cancer, there are a number of factors that must be evaluated in order to make a decision. I'm hoping you can have a good discussion with your doctor about these factors.

JimC
Forum moderator