4th line treatment - 1257617

Sat, 06/29/2013 - 09:51

Finishing his 3rd line of chemo July 11 after one year since diagnosis with NSCLC, my husband and I are at the point of considering next steps following assessment of this latest round. He has mostly maintained good vital signs-BP,O-2, HR, stable blood work w/some ups and downs. The exception of the chronic cough for nearly 2 yrs now, hemoptysis, extreme fatigue (perhaps from this round of chemo or just the cumulative effect of cough) and now PleurX catheter + recent weeks' weight loss, both to be evaluated next week.

Knowing from other posts that a 4th line offers limited success, we wonder about exploring other avenues of treatment such as the targeted, precision treatment or a clinical trial. The doctor believes b/c of current fatigue he is not a candidate for trials and has offered a 4th round or palliative care. We are not willing to give up, our faith promises "Nothing is impossible with God," yet want to face what we may be inevitable.

Are there actually successful 4th line chemo or other treatments? From what we read, the %s appear extremely low. From your experience can you offer other direction to explore or other encouragement?
We appreciate any thoughts you have on this.

NSCLC adenocarcinoma 6/18/2012-ULL resected tumor arround pulmonary artery, mediastinal lymph node met; 1st line: chemoradiation ~Carboplatin+Pacitaxel (PET=lung clear >rest for 3 mo); hemoptysis/chronic cough, 1/18/13 neck biopsy skin> adenocarcinoma,1/22/13~w/met indications-(PET/CT) clavical, spine & iliac,2nd line~Taxotere+Zometa; 4/22/13(PET-CT pleural effusion possibly masking ULL malig. activity+other scattered uptake) 5/2/13~3rd 3rd line=chemo~Alimta+Carboplatin , rigid bronch>ablation/cauterization>hemoptysis,cancer in trachea, 6/13/13=PleurX catheter placement, complete 3rd line 7/11/13;

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double trouble

The moderators and staff will respond soon. I am a patient, so I can't address most of your questions, but I did want to make the point that this should not be a palliative care (OR) 4th line decision. Palliative care is appropriate for any patient and their family from the point of first diagnosis on. They offer help with symptom and side effect control, can help access social resources, offer spiritual support and so much more. They should be a team that can help you pull all of the loose ends together to form a cohesive picture of what is going on. I strongly recommend it. Then if you do move on to 4th line, you have that much more support. Nothing about accepting palliative care suggests you are "giving up."

I think you might be confusing palliative support with hospice care which is not "giving up" either, but is different from palliative care.

I'll be looking for your posts and I hope you find some answers soon. You've been on a tough journey so far.



Actually Deb with stage IV, they call all treatment palliative unless it's oglio-metastatic. Surprised you've not seen this before. They're basically treating the cancer to reduce the symptoms. Take care, Judy


Has your husband's tumor tissue been tested for any mutations? This could be the key to any further options, although perhaps Tarceva is still a possibility, even if negative for EGFR mut?

Best of luck,

Dr West

To try to address some of the issues around the word palliative, there's good reason for confusion. Palliative really means just treatment that can't feasibly be considered as curative, so Judy's very right in saying that all treatments for advanced disease that aren't in the setting of a very limited amount of disease that might feasibly be treated for cure is palliative. Even first line treatment of metastatic lung cancer is palliative in the sense that the goal may be to improve survival by months or years, but it's not generally realistic to be treating with curative intent.

I believe that Debra's point is that the goals of therapy should be to address and minimize cancer-related symptoms along with treatment-related side effects as we also work to improve survival as we can. Particularly in later lines of treatment, but even in first or second line treatment of advanced lung cancers, we should be trying to improve quality as well as quantity of life, rather than consider them mutually exclusive efforts.

To address the question of what the benefit is from 4th line or later, it's appropriate to note that there is no proven value to any treatment in that setting or later. There are certainly occasional patients who benefit, almost all of whom were major beneficiaries of earlier lines of treatment who responded very well to their second and third line therapies before that. However, as we move from second to third to fourth line, the probability of benefit declines as the risk of net harm escalates, so there is a very real risk that it will do more harm than good as a patient becomes more depleted and the cancer becomes more resistant to treatments. I think that it's important to be mindful if the treatment is primarily being given because of momentum and a blind desire to never stop, even if it may be reaching a point where more treatment is more likely to shorten than lengthen a person's survival. That does happen.

Good luck.

-Dr. West


Thank you, Judy, Debra and Dr. West for your responses. They were helpful. Hours after my first post, my husband was hospitalized for pneumonia.

double trouble

Oh Norma, I'm sorry. I hope he is recovering, and that you have some support for yourself. I will be looking for your updates keeping you both in my thoughts.




I am sorry to hear about your husband's recent complication w/pneumonia. Just wanted to let you know that you are both being thought about and I'm sending my best for comfort for your husband and peace for you both in your decisions.