We just had the sad news that my mother´s cancer did not respond to Tarceva, although she has the EGFR mutation. The cancer has spread to the bones, and now recently to the liver. She was diagnosed March 5, and Tarceva was her first line treatment.
I have so many questions:
1. Is now Alimta + Carboplatin the next "cutting-edge" medicine for us?
2. Was Tarceva given as first-line treatment a huge mistake? Should we have given her chemo first and waited with the Tarceva to use as a second-line treatment?
3. My mother took Somac (a proton pump inhibitor) for the first 5-6 weeks of her treatment, before the Pharmacy called her and told her she had to stop because it could affect the effect of the Tarceva. What damage has her taking Somac together with Tarceva possibly done?
4. She never had symptoms from Tarceva, except for a mild diarrhea. No rash. Was this probably a sign that the medicine didn´t work?
Thank you so much for responding to my questions.
All the best
Reply # - July 22, 2012, 05:17 PM
Reply To: EGFR positive but Tarceva doesn´t work – lung cancer
haugesund, I can imagine how disappointed and worried you all must be, especially your mom.
I am going to send a request to have a faculty member respond on whether or not a trial drug may for acquired resistance may be a possibility for your mom since she tested positive for the EGFR mutation.
Other than a trial her options would look like those of anyone else with an adenocarcinoma nsclc. Here is a blog/post outlining the options and yes alimta and carboplatin are among the top platinum based doublets given to adeno. I'm assuming it is adenocarcinoma because of the mutation, however if she has squamous cell then alimta isn't an option. Many if not most oncologist today would start a patient with an egfr mutation on tarceva first line so I hope you don't worry that your mom isn't getting excellent treatment because of that choice. The links below answer the question of first line treatments. Since your mom had tarceva first the doublets mentioned are used 2nd line.
http://cancergrace.org/lung/2010/04/16/introduction-to-first-line-thera… and http://cancergrace.org/lung/2010/09/18/lung-faq-ive-just-been-diagnosed…
While there is some correspondence between response to tarceva and a rash it isn't at all large enough to make a guess for one person. People get the rash but no response and vis versa. http://cancergrace.org/lung/2011/02/21/faq-egfr-inhibitor-rash-assoc/
A second opinion at a major lung cancer center would be able to shed light on trials that have promise for your mom's situation.
I hope your mother does well on her next line.
Janine
Reply # - July 22, 2012, 05:30 PM
Reply To: EGFR positive but Tarceva doesn´t work – lung cancer
Dr. West can you also respond to question # 3. thanks
Reply # - July 22, 2012, 06:39 PM
Reply To: EGFR positive but Tarceva doesn´t work – lung cancer
I really agree overall with what Janine had to say, but I'll try to add a bit.
1) There definitely isn't any one clear best choice for treatment now, but most experts would favor starting standard chemotherapy with or without Avastin (bevacizumab), and the carboplatin/Alimta (pemetrexed) regimen would be among the leading options here.
2) First line Tarceva (erlotinib) or Iressa (gefitinib) would be the top choice as first line therapy for someone with a known EGFR mutation for just about every lung cancer expert on the planet. The response rate is about 70%, which means that 30% don't show a response. That may be because many of those people start our with a resistance mutation as well, or the mutation that was detected in her isn't one of the more common ones.
For whatever reason, not everyone who has an EGFR mutation responds to an EGFR inhibitor -- but that doesn't mean it was a bad choice. We just don't know why around a third of the people with an EGFR mutation have a relatively disappointing response.
3) Probably not. Proton pump inhibitors (PPIs) can decrease the uptake of oral EGFR inhibitors, but the limited evidence that exists actually shows that people who were on a PPI while they took Tarceva didn't do any worse than the people who weren't. Moreover, many of the people who have an EGFR mutation are extremely sensitive to EGFR inhibitors, so even getting a reduced dose often leads to a great response.
4) Not really. While there is a correlation of better results in people who develop a rash, and particularly a bad rash, there are so many exceptions that this isn't a very helpful guide. Some of the people who have had the worst Tarceva-induced rashes I've ever seen didn't respond at all, while I have several patients who are doing sensationally well for well over a year, some now 2-3 years on treatment, with barely a pimple in that time.
Good luck.
-Dr. West
Reply # - July 23, 2012, 01:14 AM
Reply To: EGFR positive but Tarceva doesn´t work – lung cancer
Haugesund, I'm really sorry to hear about your mother. I hope you and your family are not blaming yourselves, and are reassured to some degree by what Dr West says. Keep us posted.