Sudden weakness, and 2nd line gemcitabine for 79 yr old - 1245181

Jazz
Posts:279

Hi Faculty,

Sorry about these two very different questions. Re: My father, 79 y.o. dx stage 4 July 2011, untested, prev. light smoker 42 years ago. Adeno, non-squamous, primary tumour near trachea. Tarceva for 1 month, "allergic" reaction (high liver enzymes, onc pulled him off for a month). 4 cycles Carbo/Alimta = liver nodule shrank but new nodules in prev. clear right lung. Onc placed him on Alimta maintenance anyway for the past 10 months (citing tolerability edging out benefit). Progression noted on last 3 scans, but his oncologist keeps saying it's a slow growing cancer, progression is very slight, no need for change. This oncologist said if my father wanted to switch agents, he would have to take a 6-week break to get over side effects (which is just constipation and fatigue), and then onc would give him Taxotere. When asked about this, he said Taxotere is standard 2nd line and there's nothing exiciting about gemcitabine. I don't find this oncologist sympathetic or attentive towards my father, but my father is very old-school and fears insulting this doctor by seeking a 2nd opinion.

Question 1: Isn't Taxotere more difficult than Gemzar for the elderly (he's a fit 79 y.o. but has become more frail lately. Still independent, doing all IADL's)? I've reviewed Dr. Lillenbaum's videocast and some other articles and they all seem to point to Gemzar or Navelbine for older patients.

Question 2: Yesterday (3 days after his last Alimta infusion) he was suddenly very weak - couldn't stand, walk, or do anything (of course didn't call anyone!). Today he feels better, but as he put it, "I thought I was going to die." What could bring on such sudden weakness, unaccompanied by pain, and is this something that has been seen with Alimta in older patients? He will report it tomorrow, but should I be looking for other symptoms?

He has no other co-morbidities except macular degeneration in one eye, and it seems he's now developed a leaky heart valve.

Thanks,
Jaz

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Reply # - July 16, 2012, 04:32 AM

mpinder
Posts: 42

Dear Jazz,

In my experience, Taxotere is more toxic than Gemzar, particularly in the elderly. Some oncologists will give weekly Taxotere rather than every three week Taxotere in elderly patients because patients usually handle it a little better. It is true that Taxotere is an FDA-approved second-line regimen while Gemzar is not. That being said, Gemzar is an active agent in lung cancer.

I am not sure what caused your father's sudden onset weakness. Sometimes just cumulative toxicity from chemotherapy can cause severe fatigue and I have seen some patients develop significant fatigue after many cycles of Alimta. In any patient, though especially in the elderly, I'd want to rule other issues (infection, low blood counts, etc.). The fact that it got better on its own is reassuring, though.

All the best to you and your Dad.

Dr. Pinder

Reply # - July 19, 2012, 07:06 PM

Jazz
Posts: 279

Thank you very much, Dr. Pinder. Great to see you back, we've missed you!

My Dad seems to have recovered from the episode of weakness. When asked about changing agents, his oncologist stated he would take my Dad off chemo for 6 weeks to recover from side effects (constipation and fatigue) before switching. 6 weeks seems a long time to go without treatment, and I'm not certain why his oncologist feels my Dad's is a slow-growing cancer, as he's progressed through treatment so far (including 1st line - 4 cycles of carbo/alimta). Any insight as to the waiting period between treatments?

Jazz

Reply # - July 19, 2012, 09:14 PM

Dr West
Posts: 4735

It really depends on the person -- the pace of their cancer and their degree of side effects -- but we often see lingering effects from chemo for a good few weeks after someone goes on a hiatus. Because of that, I would anticipate it taking 4-6 weeks to really see someone recover from challenging chemo well enough to reassess the situation.

There are certainly some people who can experience torrid progression in less than a month, but that's a real minority of patients. As for your father, even when you can see progression in someone, that's not always the same as fast progression. Perhaps that's the case with your father. If it's more of a gradual, inexorable progression, that doesn't necessarily imply anything extremely aggressive, even despite his history of progression on prior treatment.

-Dr. West

Reply # - July 20, 2012, 11:01 AM

mpinder
Posts: 42

Jazz,

Thanks - it is good to be back!

I'd agree with Dr. West that it generally takes 4-6 weeks for someone to recover if they've experienced significant chemotherapy toxicity. I'd also agree that progression may be quite slow and that patients can sometimes experience the same amount of slow progression off therapy as they did on therapy.

In general, if a patient is progressing slowly and I was concerned about chemo toxicity, I would tend to err more on the side of giving a little extra time to recover. In my experience, forging ahead when the side effects of chemo are still lingering can be counter-productive, particularly if symptoms of the cancer are minimal.

Dr. Pinder

Reply # - July 20, 2012, 06:11 PM

Jazz
Posts: 279

Thank you very much, Drs. Pinder and West. I feel greatly reassured, and will give my father this information. We'll probably seek a second opinion after his next bone and CT scan, as it's likely his oncologist will choose Taxotere no matter what sort of literature I can offer against the choice. My father is also allergic to many things (iodine contrast, for example), so I fear he'll react to the solvent in Taxotere if not the actual taxane (which I'm allergic to). I was very strong when first diagnosed and I had a terrible time with Taxotere, so I wouldn't wish that on him, and a weekly infusion regimen would impact his quality of life negatively (they live 20 miles from hospital). While I know everyone's different, gemcitabine was a huge relief for me when I was switched.

Jazz

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