Is this a recommendable 2nd line treatment for a NSCLC adeno?! - 1250500

meli80
Posts:24

Hello,

my mom (68), a former smoker, was diagnosed in May 2012 with NSCLC (NOS), stage IIIB - immuno-chemic histology is in favour of adeno (squamos and large cell have been excluded).

She was and is in an excellent overall condition. She was put on cis/vinorelbine and concurrent radiation therapy (32 fractions, total 64Gy). She completed three chemo cycles, the 4th was not give due to low white blood counts. The CT scan after the second chemo, that was at the same time 6 weeks after the completion of the radiotherapy, showed a significant shrinkage of the main tumor from 6.6cm to 2.6cm. That was on 20/08/2012. On 23/08/2012 she received the third chemo cycle and had some issues as outlined above.

On 14/11/2012 the first CT scan was done after the complete therapy. The tumor in the lung did not show any progress. But two lesions of the size 1.8cm were detected in the liver that were not there as of 20/08/2012.

Mom still feels very well and all of this came as a huge shock to all of us - especially since she responded so well and the abdomen CT was all clear only 3 monhts ago.

We have heard so far two opinions on the 2nd line treatment. First - only taxotere. Second (from the lung cancer center she was treated at): cis/alimta and then CT/MRT after two cycles. I feel like the guys at the center know better what to do. What puzzles me is that they would give again cisplatin. She tolerated it quite well (no nausea, no hearing loss, no neuropathia, just low WBC). But from what I've read here, it does not seem to be the "usual" 2nd line combination and that they usually give only Alimta if the person progressed while on cisplatin (or shortly after like in my mom's case). Or am I wrong? What would be the rational to give cisplatin in addition? I guess they must be counting on better results in the combo.

The EGFR tests have been initiated, we don't know the results yet though.

Many thanks in advance and kind regards,
Meli

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Reply # - November 22, 2012, 09:21 AM

certain spring
Posts: 762

Hallo Meli. I'm sorry to hear about your mother's progression, especially when she seemed to be doing well. You're absolutely right that platinum drugs like cisplatin are mostly used in first-line therapy, as they tend to wear people down. It's also true that oncologists tend not to revisit a drug they have already used, unless it has been particularly successful. So your question about the rationale for a 2nd-line cisplatin/Alimta combo is a very good one, and one of the doctors will respond (though perhaps not till later today or tomorrow, today being Thanksgiving. Hopefully they are all eating turkey and pumpkin pie!)
Glad to hear your mother is feeling well, and it is good that she has had EGFR testing - always useful to have as much information as possible. Best wishes.

Reply # - November 22, 2012, 11:41 AM

Dr West
Posts: 4735

Giving doublet chemo isn't the evidence-based treatment for second line therapy in someone who has progressed on first line therapy, but I can understand the rationale. There isn't evidence that people receiving a doublet chemo live longer than people receiving single agent chemotherapy. On the other hand, it's hard to envision that someone who has progressed on a good doublet as first line therapy will do better with single agent treatment in the second line setting. So clear progression after a good doublet might lead us to consider a doublet not because there is evidence it's a great idea, but because we suspect that there is very little chance that the evidence-based answer will lead to a result we're happy with. You can therefore make an argument that there isn't evidence to support the doublet, but there's little to lose by trying.

As a style point, I'd be more likely to select individual agents that weren't given previously, but it's not as if there are any rules here to define a best approach.

Good luck.

-Dr. West

Reply # - November 22, 2012, 04:34 PM

catdander
Posts:

Dr. West, I wonder if it matters that she received her last chemo treatment 23 Aug and was found to have liver mets 14 Nov. (20 Aug being the first CT during tx with quite a bit of shrinkage in the lung). What is the significance of progressing on treatment compared to progressing soon after concurrent tx?

Hello Meli, I hope your mom does well with the treatment she decides on.
Janine

Reply # - November 22, 2012, 07:16 PM

Dr West
Posts: 4735

The significance of the interval is that it isn't necessarily the case that she progressed right through first line chemo, so she therefore might not be resistant to it. This would make it a stronger consideration to return to one or perhaps both of the previously used agents, but again, it's a judgment call.

-Dr. West

Reply # - November 23, 2012, 12:39 AM

meli80
Posts: 24

Dr. West, thank you very much for your opinion and thorough explanations. This reassures us that my mom is in good hands in Germany. I had here, in Austria, a somewhat strange discussion with the oncologist. He suggested as an alternative to Taxotere also to wait for another month and see what are the dynamics of the lesions. In Germany, we were told not to wait because the changes were too big in such a brief time - so, a lot of confusion on our side.

I also do not think that she was resistant to the 1st line chemo. The first x-ray after the beginning of the first line treatment was done approx. 10 days after having received the first chemo cocktail and maybe 3 days after the beginning of the radiation. And the x-ray images showed a shrinkage of 20% already, which I can hardly attribute solely to the radiation.

What worries us is the sudden, quick and significant progression in the liver.

From your experience, can things on the 2nd line of treatment also stabilise for a while?

This has demotivated and scared her and all of us very much, she seems sceptic if the chemo will help her.

Certain Spring and Catdander - thank you very much for your kind words and wishes, as well as for your utmost valuable inputs and questions and your contribution to this discussion. All the best wishes!

Meli

Reply # - November 23, 2012, 02:37 AM

certain spring
Posts: 762

I wonder if the confusing advice you have had is not so much about national differences (Germany/Austria) but more to do with different habits and practices among doctors and hospitals. I am also in Europe (UK), and the various hospitals I have been treated at all have different ways of doing things. In some parts of the country they are very keen on giving Taxotere, not least because it's cheaper than some off the alternatives.
I'm not a doctor but, just from what I've read on this site, I have the impression that it is possible for someone to stabilise on second-line treatment, even with liver mets. I think an important consideration is how your mother feels about the prospect of more chemotherapy. It's a difficult decision. Can she wait until the EGFR results are back before deciding?
You have excellent English, if I may say so! Best wishes.

Reply # - November 23, 2012, 10:18 AM

catdander
Posts:

As always I wish I could have stated it like certain spring. In the US you also find very differing options for treatment.
There are at least 2 ways the biology of an individuals cancer declares itself. nsclc will differ greatly from one person to another by how quickly it grows. But it also differs in how well it responds to treatment.
And you then have all the possible combinations. Possibly your mom has a cancer that responds well but grows quicker than others when not being treated.

I hope you and your mom can find hope in all this. There is real reason to believe she can remain on treatment for a long time.

When does the onc expect to hear back from mutations testing?

All the Best.

Reply # - November 23, 2012, 10:39 AM

Dr West
Posts: 4735

It's certainly very possible to see second line treatment lead to stabilization of the disease for a while even if significant shrinkage isn't very likely. How long that lasts tends to be inversely correlated with the aggressiveness of the cancer and how long it takes for the cancer to show progression after first line therapy has been completed.

-Dr. West

Reply # - November 24, 2012, 04:11 AM

meli80
Posts: 24

When I read what has been written, I understand that chances my mom stays stable with the 2nd line treatment are low. And this devastates me.

The fact that this disease has no rules is at times driving me literally insane. I don't think that her cancer is especially aggressive based on the "facts", because the doctors told us that the cancer proliferation rate established based on the tissue from the biopsy was 25% - 35%. And that was - according to them - the normal growth range for adeno. But then again, she developed two mets in the liver - in an untypical area according to the oncologist - very deep, close to the vena cava inferior - making a biopsy very risky, so they do not want to risk it. Mets AFTER the therapy and despite a good response to the tx - this all makes no sense to me, which makes me fear this disease even more.

She has no symptoms at all yet - if she would just stay stable, without any tumor shrinkage - I would be eternally grateful.

I am trying to support her immune systeme before the chemo with all kind of supplements (e.g. beta glucan, green tea, pomegranate juice, berries, vitamin B12 and folic acid because of Alimta prospect). If you know any additional advise, please let me know.

Certain Spring and Catdander, thank you very much for your kind words. Mom is ready to fight, since she feels still strong. She is not declining a chemo. Plus, she trusts her doctors in Germany (same as me) and would do their proposed treatment. Austria is a very small country, I believe that their treatment options are more "generic" then in case of a specialized lung cancer center, maybe that's why they use standard approaches like Taxotere. But, it could be a question of costs or hospital styles as you say. Thank you for the compliment - I learned English from my dear mom, who was an English teacher. English and much more that makes me the person that I am today... I love her so much.

EGFR tests - should be this week!

Thank you again and all the best!

Reply # - November 24, 2012, 05:05 AM

certain spring
Posts: 762

I really wouldn't despair yet, and I am a quick despairer! Your mother may respond well to this new combination and have a period of stability. It's also a good sign that she has no symptoms. A person who is feeling strong is in a much better condition to go through through chemotherapy than someone who is already weakened by cancer.
Don't let it drive you insane. Cancer is horribly unpredictable, and you're absolutely right that there are no rules. But that uncertainty could work in your mother's favour as well as against her. People on GRACE often describe it as a roller-coaster experience, but that means that many of us have had ups as well as downs. You'll learn to hold your nerve, and that will help your mother. Keep us posted.

Reply # - November 26, 2012, 02:30 AM

meli80
Posts: 24

Dear Certain Spring, thank you so much for your encouraging words. I will keep you posted about the further steps.

I have a question to Dr. West - you most probably know about the clinical trial for the vaccine Stimuvax for advanced NSCLC, which is currently in its 3. test phase. It sounds very promissing so far and the results of the third phase testing will be published in Q1 2013. What is your opinion to this vaccine and how long does it take from your experience until such a vaccine is admitted to the pharma-market?

Once again, many thanks in advance!

Meli

Reply # - November 26, 2012, 03:01 AM

certain spring
Posts: 762

My pleasure. Cancer imposes terrible strains on people, and you will find many here who sympathise with your feeling of powerlessness..
On Stimuvax, I am sure Dr West will answer when he comes on later in the day. However you might like to look at this post (also available as audio) by Dr Govindan, who summaries the latest developments:
http://cancergrace.org/lung/tag/stimuvax/
http://cancergrace.org/lung/files/2012/06/Govindan-Immunotherapies-for-…
My impression from reading his account is that Stimuvax seems most promising for people with stage III cancer, and for those whose cancer has stabilized.
On your earlier question - why progression in the liver after such a good early response? - it does make sense to me. Researchers are learning more about the different cells involved in cancer. Some of these cells may be responsive/sensitive to certain treatments, while others aren't. So some of the cancer cells might have responded to chemo/radiation while others didn't, and the ones that didn't migrated/spread to the liver. I've no idea if this is true in your mother's case, but it is something that can and does happen. All best.

Reply # - November 26, 2012, 08:41 AM

catdander
Posts:

Meli, I don't think we are going to get anymore updated info than what certain spring is offering. That info will usually be found in a new blog/post. So don't forget to keep an eye out for new info on that part of the Grace site.

Just an FYI, depending on your browser (I changed over to safari but others work too) you may need to log out to access the first link in the previous post (because it's a link to a search result). This is true too to use our search function. I'm not sure how far this oddity of WordPress goes but this is what I've noted so far. Too, newer versions of Explorer may accommodate this by now.

I love your mention of the gifts your mom has given you, she sounds smart and loving.
Janine

Reply # - November 26, 2012, 07:24 PM

Dr West
Posts: 4735

I think that if the Stimuvax trial is positive and presented in the first half of 2013, it would likely be about a year from now at the earliest that we might see the treatment become commercially. And if it is approved, it will be approved as consolidation therapy for patients with stage III NSCLC after completion of chemo and radiation, but not for other settings, such as post-operative therapy for earlier stage NSCLC or advanced/metastatic NSCLC.

-Dr. West

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