Greetings to All,
The Quintiles study [http://www.sciencedaily.com/releases/2011/11/111114095721.htm] indicates those with KRAS nonamplified mutation have shown good results with Alimta. I have the KRAS mutation but do not know whether wild type, amplified, or nonamplified.
After 9 months without treatment with slight, e.g. from 1.4 cm to 1.7 cm over 3-6 months, but seemingly inexorable progression, we are considering starting Alimta, maybe with Avastin.
Should I know nature of my KRAS mutation before starting Alimta as it seems to be effective only with nonamplified KRAS?
If I go ahead without knowing if nonamplified, should I do Alimta alone or with Avastin? Are any results from ECOG 5508 available to help answer this question?
As always, thanks much for all that this site does.
Wed, 10/24/2012 - 11:04
Hi Nan, thanks for the update. I'm sorry it appears that your cancer is growing but it's good to hear your nodule is progressing at such a slight rate. When a cancer has proven itself as indolent as yours many doctors would watch it for another 3 months after a scan that showed 3 mm change. some would say it may not even be a change but a difference in the cut of the scans.
Either way, the watch and wait approach has many advantages. You don't have to be treated with the toxic drugs that cause nasty, sometimes debilitating side effects and you won't need to go into the cancer center as often. But must of all the sooner you begin treatment the sooner you will become resistant to its efficacy or incapable to continue treatment because its intolerability.
I don't think it will matter whether your KRAS is amplified or not when you need treatment Alimta will still be a good option. Whether to add Avastin may have more to do with your insurance than any understanding we have of its possible value. There just isn't any good data showing that it will help, but it is very expensive and has its own set of side effects.
The ECOG 5508 is still recruiting so no results yet.
The term wild type just means you don't have the mutation at all. e.g., you're egfr wild type.
It sounds like you are doing very well. Don't hesitate to ask more questions and please let us know what you decide.
Wed, 10/24/2012 - 17:10
Janine is exactly correct about both important questions. No, there is no clear need to do KRAS testing, as Alimta (pemetrexed) is appropriate for a much broader population of patients with nonsquamous NSCLC.
I would consider the maintenance therapy data to be marginally more effective with the combination of Alimta and Avastin (bevacizumab) than Avastin alone, but we don't know about Alimta alone. I'm getting refusals from some insurers on the combination, and my preference is to give Alimta over Avastin. There are currently no data to say that the combination is definitively better than either alone.
And as Janine said, the ECOG 5508 trial is a great one to help answer the question, but it's still being asked right now.
Fri, 10/26/2012 - 05:22
Thanks Dr West and Janine,
To clarify, I have multiple lesions, none of which have progressed rapidly over the two years since my lobectomy. No treatment for a year with modest growth starting in the second half of that year. Then, a year ago, I had 4 cycles of carbo, alimta, and avastin, followed by stability for 6 months, then 6 months of modest growth...1-3mm between 3-month scans. We are looking at starting treatment again.
Is there something I should consider other than avastin +alimta?
Fri, 10/26/2012 - 06:13
That's a bigger question than we can answer. It's reasonable to do Alimta or Avastin alone, or in combination, Tarceva (erlotinib), Taxotere (docetaxel), possibly a clinical trial. There just aren't data to say that one of these approaches is clearly better than another, and that's why it's probably best to say that these options should be discussed with your oncologist for an individualized recommended strategy.
Tue, 01/29/2013 - 07:24
Here I come again, seeking the thoughts of the Grace community to help me sort out my situation.
Since the Oct, 2012, posts, I have done 4 cycles of Alimta and Avastin together. Once again, scans after two and then after four treatments have not revealed any progression. I say "once again" because, as described in my Oct 26, 2012, post above, there seems to be a pattern of periods of no growth followed by modest growth, followed by treatment, etc.
I am fortunate, I know, to be talking about no growth over periods of up to six months. But would I be pushing my luck to count on the pattern continuing? Would it be reasonable to suspend treatment now instead of going on with two more treatments, scan in three months, and resume treatment if that scan shows progression?
In that case, would I again use Alimta and Avastin on the assumption that they have been effective? Or maybe, Alimta alone?
As always, I am most appreciative of all that Grace does
Tue, 01/29/2013 - 13:51
Hi Nan, I'm so happy you have continued a slow/indolent rate. From what I understand you have ever right to hope and expect it to continue on this path. As always I've pasted links for consideration. I hope I'm not overwhelming you with them but there new and I think they all pertain to you. The first if promising treatment for KRAS, the second on treatment BAC using an algorithm proposed by Dr. West, and the last is actually exactly pertaining to your most recent question about treating to an individuals' cancer biology and rate of growth.
I hope this is helpful,
Tue, 01/29/2013 - 17:34
Janinequilts, Thank you for pointing me to the pertinent links. It is helpful.
Tue, 01/29/2013 - 20:27
Yes, in patients who are showing stable disease, I don't hesitate to offer a break from chemo and consider resumption of the prior regimen, or part of it, to be a fine option if there hasn't been any significant progression on it.
There is always a risk that the cancer will change its behavior, and there is always a risk that the cancer won't respond to the treatment the second time around, but there are also very real risks to continuing treatment, especially if it's more treatment than is really needed to control the disease at a given time.
Though it may sound trite, it's completely true that cancer can do anything, so you always need to accept some uncertainty but make the best judgment you can based on the information and probabilities available, rather than live by what is remotely possible. And it's also helpful to consider that there are risks and benefits to ALL options, not just one in isolation. So factor in the risks as well as benefits of continuing treatment, as you calculate the risk/benefit balance of taking a break from it.
Wed, 01/30/2013 - 06:00
Thank you Dr. West for your observations which are always so helpful.
Wed, 01/30/2013 - 11:35
I had to add that since your user name was obvious. Truthfully machine quilting is a newish hobby which I'm really enjoying making cuddly quilts for family. I've done needle work all my life but not a master at any of it.
Hopes for continued indolent cancer.