Third line strategy after progression - 1247698

apra
Posts:142

We met the doctors yesterday and today to discuss in detail the strategy to be followed after my husband's progression, two different oncologists and one radiologist.

The progression in the bones has resulted in new mets in right femur, right iliac bone and L5 vertebral abnormalities. Mild ascites and right pleural effusion and multiple military nodes.

Such extensive progression seem to suggest that the Alimta was not working for sometime.

Our previous onc suggested Tarceva 150 mg and samarium radio nucleides for the bone mets, as radiation is now not possible. He said this technique would lessen the bone pain and also strengthen the bone as well as kill some of the cancer.

This last option seems to be ver attractive. We met the nuclear medicine doctor and they may do the procedure in a day or two. They said they do it only once a month as there are not many candidates for this therapy.

Can you tell me more about this radio nuclide therapy? Is it good for lessening the pain and strengthening the bone as well as reducing the cancer in the bones?

Thank you

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Reply # - September 5, 2012, 01:22 PM

Dr West
Posts: 4735

It is primarily done for patients who have pretty widespread metastatic disease involving the bones. I would say that the primary goal of injected radionucline therapy like samarium is to improve pain related to bone metastases. Here's a post about it from several years ago:

http://cancergrace.org/radiation/2007/02/20/radiopharmaceuticals-for-bo…

There isn't much to add since then.

Good luck with upcoming treatment.

-Dr. West

Reply # - September 5, 2012, 10:30 PM

apra
Posts: 142

Dr. West,

Thank you so much. Yourost was very effective. Your post stated that :

This is what I am concerned about. My husband has to start on Tarceva soon, so will this procedure hamper him from taking this medicine. Or can they be done together? Can Tarceva be taken while such a procedure is also being done? And how long does the pain relief last?

My husband is having significant pain from bone mets, the pain is now controlled by pain medications like Ultracet and Gabapentin.

The new bone mets are in the three places mentioned above, while the old bone mets are also not entirely healed but the radiologist says 'persistent mild sclerotic lesions' is nothing to worry about.

Thank you.

Reply # - September 6, 2012, 08:17 AM

Dr West
Posts: 4735

Tarceva (erlotinib) doesn't typically lead to significantly lower blood counts, so it wouldn't have the same limitations as trying to give chemo after injection of a radiopharmaceutical.

Pain relief tends to last for at least months, sometimes even indefinitely.

-Dr. West

Reply # - September 6, 2012, 11:56 AM

apra
Posts: 142

Dr. West,

You are truly a pearl of great price. May God continue to use you to bless many others.

Today the tooth extraction was done. On 27th Sept. the radio pharmaceutical salarim will be necked. On Tuesday, the 11th, the biopsy report will be out which will then be sent for mutation tests.

By the grace of God, we are praying tha he has a treatable mutation. In the meantime we will be starting the Tarcva on Wednesday.

Thank you and God bless.

Apra

Reply # - September 7, 2012, 06:38 AM

apra
Posts: 142

Thank you for your good wishes Certainspring. As your name suggests, if winter is here, can spring be far away? I believe you are still on Tarceva and doing well.

When you declined second line Taxotere, perhaps you went without treatment for more than two months? I think yours is one of the rare cases of squamous LC being EGFR positive. I thought the mutations existed only in Adenocarcinoma.

May the good days continue.

Reply # - September 7, 2012, 07:13 AM

catdander
Posts:

That's right. EGFR mutation is rare in squamous, however people who don't smoke are not likely to have squamous nsclc. So certain spring had the mutation testing done on her own dime. And good thing she did!

Reply # - September 7, 2012, 10:36 AM

certain spring
Posts: 762

Thank you. I have very been lucky with the mutation. In fact I don't smoke. My parents however both smoked heavily: I think that may be the reason why my tumour is squamous.
I was off treatment for four or five months. I suppose the reason I have that in my signature is to suggest that things can get better as well as worse within the time that is left to us. I hope you'll see better times with your husband, Apra.

Reply # - September 7, 2012, 01:10 PM

catdander
Posts:

Great Apra, I will look forward to it! D too had many complications at the beginning of all this.
I think it's so important for others to know that better times can be a reality.
We are now getting ready for several days on the river and we're having such a good time pulling all our equipment together!

Reply # - September 7, 2012, 01:36 PM

sylyx2005
Posts: 14

Apra, best wishes for your hubby's incoming Tarceva treatment.

Certain spring, I thought Tarceva is perfect served as maintainance drug, any particular reason for you off the treatment for few months?

Reply # - September 8, 2012, 02:45 AM

certain spring
Posts: 762

Yan, to answer your question (sorry Apra for interrupting your thread), I have an aggressive cancer that grew through first-line chemotherapy. Tarceva was not an option at the time, and I was too ill to have any more treatment. When I was better I chose not to have the second-line chemotherapy that was offered to us. As Janine explained, I am only on Tarceva because we lobbied hard for the mutation testing (I am in the UK and it was not standard practice at that time, though I am glad to say it is becoming more common). I am not sure I would describe the Tarceva as maintenance: I have every reason to believe that if I came off it the cancer would start growing again.
Best to you and your husband, and I hope his experience on the clinical trial is a good one.

Reply # - September 8, 2012, 04:35 AM

apra
Posts: 142

Janine, happy sailing, we will join you next month with our friends Stable or NED:)

Yan, thank you for your good wishes.

Certainspring, how many mg are you on? My husband's onc's are giving two numbers. The first onc says 150 mg is the standard dose, he should start on that, the second onc says start with 100 mg and if he tolerates that well then we will increase. How sick were you when you started Tarceva? Sorry for so many questions.

I am confused. I hope the doctors can also throw light. I though you should start on a higher dose and if it is intolerable, to slowly bring it down. Won't starting on a lower dose be ineffective? Even if the medication were to work, maybe because it's a lower dose, it would not be effective.

I am in favour of starting on 150mg but he says 100 as he is a little weak from the progression and alimta. Although his PF is ok. He can help himself, go anywhere, albeit a little slowly, weight remains stable at 80 kgs, eating ok.

Any studies on starting at a lower dose and slowly creeping up? Or giving a lower than normal dose and still reaping the same benefits?

Reply # - September 8, 2012, 08:13 AM

catdander
Posts:

I just responded to your other thread. The typical moa is to keep the dose where it is as long as it's working for most people, which tarceva is. So there aren't studies being conducted on lowering doses. That is something each doctor will do on her own. Mostly the full dose is given up front then lowering as needed.
My husband's doctor has and does non standard things with my husband. One of which was give him 100mg tarceva up front because he was in a very weaken stage. He remained on the drug at that level for 10 months.

Reply # - September 8, 2012, 12:23 PM

1813r
Posts: 7

Wishing you the best on tarceva. It did not work for me, probably caused a bleeding ulcer as well. Went on taxol as 3rd line but developed radiation pneumonitis which was treated with steroids. Returned to try taxol again as scan showed it was containing nodule growth. Unfortunately, pneumonitis returned after one taxol chemo so back on steroids and will discuss other chemo options next week. Do any other chemo drugs exacerbate pneumonitis ? Although cancer has not spread outside of lungs, I feel like everything I try causes other problems. Anyone else have this pneumonitis problem?
Certain Spring is an inspiration for all of us!

Reply # - September 8, 2012, 04:29 PM

Dr West
Posts: 4735

There are no studies that speak to the issue of starting at a lower dose of Tarceva (erlotinib) and then gradually increasing it. Some people do it, but I don't. As I say, I can't point to any data to guide us here, and there is no evidence to say it's a favored approach.

It is absolutely possible to under-dose the Tarceva, and that is a leading reason why most experts favor trying to treat a patient with the highest dose, up to 150 mg daily, that a patient can tolerate on a sustained basis.

-Dr. West

Reply # - September 9, 2012, 04:11 AM

certain spring
Posts: 762

Apra, I started on 150mg and am still on that dose. But it must be said that I have a stomach like iron. When I started taking Tarceva I was in relatively good shape - except that we knew that the cancer was growing and I wasn't likely to stay well for more than a couple of months.
1813r, sorry to hear about your bad experiences with Tarceva and then with the pneumonitis. I wonder if you should start a new thread about the pneumonitis, so the doctors can see it and respond? I believe there may be a rare association with Alimta:
http://cancergrace.org/forums/index.php?topic=10947.0
Some GRACE members have had good results with Naproxen, as discussed in this thread, but presumably that is out of the question with your ulcer:
http://cancergrace.org/forums/index.php/topic,10823.0.html
Best wishes.

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