radiation for progression - 1250821

As much as I'd like for that idea to be an option to keep cancer at bay it's not been shown to be the case.

Dr. West wrote, "The problem is that metastatic cancer represents a situation in which the disease we can see is almost always accompanied by additional micrometastatic disease we can’t see, but that remains under the surface and able to create new areas of metastatic spread that prevent even our most aggressive local therapies (those directed to disease in a particular area, as opposed to systemic therapies that reach throughout the body) from being truly curative. If cure is achieved by ridding the body of any viable cancer, removing or radiating even 98 or 99% isn’t going to do the job if there is more disease below our levels of detection." The entire piece can be found here, http://cancergrace.org/cancer-101/2011/01/01/cancer-101-faq-i-have-meta…

The obvious options involve chemo which has proven on Grace time and again to be a very manageable option.

All Best,
Janine

Au yes. That's a good question though you would need to compare previous size of all measurable cancer to what was found on the latest scan. Like some of my husbands scans yours are missing measurements.

The idea of radiating the spots of acquired resistance and continue tarceva is under investigation by our Dr. Weiss though it wont be a standard practice until/unless it's proven to be beneficial.

A doctor or radiologist would need to review your sequence of scans to determine how significant the progression is. It would be quite normal to see Dr. Wakelee at this juncture for review and next step options.

I really agree that this sounds very much like a situation where the progression is multifocal and not at all likely to be helped by focal treatments to individual sites. Instead, I do think that additional systemic therapy is the most appealing consideration.

The appearance of new lesions would likely constitute clinically significant progression, regardless of whether previously measurable lesions are more or less than 20% bigger.

Good luck.

-Dr. West

I'm sorry I think we missed your last question.

I'm editing this to say I think I miss understood your background. It appears you haven't had chemo yet. Is that correct?

I am going to ask another doctor to weigh in here. I know you've ask many questions about avastin, sometimes a new perspective can complete an understanding.

Good luck,
Janine

I think just adding Avastin (bevacizumab) to ongoing treatment isn't likely to fundamentally change the direction of the cancer. So while I think it might be able to nudge someone into stable disease or perhaps even a minor response in someone who is showing very slow, gradual progression, but I don't think it's likely to provide a meaningful change in someone who is demonstrating more convincing progression.

With regard to whether to add Avastin to chemo in someone who has only received targeted therapy but not chemotherapy before, we don't have any evidence to speak to that question, so we just don't know if it adds anything.

-Dr. West

Would it not add as much as anyone else starting chemo for the first time? I"m sorry I'm confused but hopefully not making it more difficult for ssflxl to come to the understanding she's looking for.

It won't ever be something I'll need to consider for D, he's squam, just covering the bases for ssflxl because I know she's (he?) been struggling with the avastin question.

Perhaps, but the value of Avastin even in first line, previously untreated patients just isn't that crushingly compelling. It hasn't been especially beneficial on a consistent basis, failing to improve survival at all in the European AVAiL trial, and with population-based studies really casting further doubt on the real benefit it offers, with just the ECOG 1505 trial showing a survival benefit in lung cancer. The setting of first chemo after acquired resistance may well be considered analogous to first line treatment overall, but the fact is that these are the patients likely to do well over a longer time than many, and that may mean that any short-term benefit from Avastin is likely to wash out over time. I think the the best answer is that first chemo-based treatment after acquired resistance to a targeted therapy is similar but not the same as first line treatment in a broader population, and I don't think we can truly presume that there is a significant survival benefit from giving Avastin here, even if it's a very reasonable thing to do.

-Dr. West

Thanks Dr. West that really is helpful.

ssflxl, fantastic that you are not coughing or short of breath, and best of luck with your appointment next week. I am following your situation (and your reasoning) with interest. Glad you have Dr Wakelee in your corner.
Does it make a difference - to your thinking, your doctors' thinking, Dr West's thinking - that you have the EGFR mutation? - which, as I understand it, confers greater sensitivity to radiation?

That's really not a well-established conclusion. I think it's a provocative preliminary finding, but it's not something that I think is firm enough to lead me to alter treatment decisions.

-Dr. West

There's nothing wrong with trying the mk 3475 because it's phase one. It's a very promising drug and since it's a phase one trial participants are assured of receiving the research drug.
Here is a blog post written in Oct. on Nexavar. http://cancergrace.org/lung/2012/10/17/mission-trial-neg-egfr-mutn-pos/

The phase one trial won't always be there (as a matter of fact I thought anti pd 1 trials were filling up quite quickly) but nexavar will. So timing may be of importance.

Good luck with the cyberknife. I'm sorry the increased dose is so hard to tolerate -- I've certainly had some patients over the years who have been exquisitely sensitive to the side effects of even doses as low as 25 to 50 mg daily, so I don't doubt it can be a real challenge. I hope your current treatment plan yields good results.

-Dr. West