Hello,
After much discussion and debate my mom's oncologist decided to put her on Afatinib (40mg) as her third line treatment after a long run on Tarceva. She managed a week and a half on the 40 mg dose of Afatinib until the side effects of constant diarrhea, extreme fatigue, mouth soreness and complete taste bud alteration(all food tastes bad) became too much. She went to the oncologist this past Monday where she was given IV fluids and told to stop taking it for a week. Her body has somewhat recovered aka no diarrhea but has left her weak and with no desire to eat. She has lost 5 lbs which she didn't have to lose. They want her to continue on with 20 mg starting Monday. She is scheduled to meet with her oncologist's PA during that time. My question is this, is it really smart to keep moving forward with this treatment or should we move to Tarceva with Alimta(or some other chemo) until a clinical trial opens up for another targeted therapy drug(AZD9291 or CO1686)? With this much toxicity I just think it is not a good idea but I don't want to act irrationally. The only thing holding my parents back,I think, is that they are receiving Afatinib for free. If the thought is Afatinib is no better or worse than another treatment in terms of effectiveness and tolerability then should we stick with it? Afatinib makes me nervous as it doesn't seem to be effective as a third line. I posed the effectiveness question to the oncologist and he seemed to think it had good durability but is that data using it as a first line for patients with stage IV? I can not find data to support it's use for my mom. Any advice,words of wisdom would greatly be appreciated. Watching my mom feel so terrible is just unbearable.
Reply # - March 6, 2014, 05:45 PM
Reply To: Alternative to Afatinib?
Hello,
I'm sorry to hear that your Mom is having such trouble tolerating Afatinib, but that's not unusual at all - it tends to be much more toxic than Tarceva. As far as its efficacy as a single agent in the acquired-resistance/second-line context, that's really not well-established, as Dr. West described in these posts:
http://cancergrace.org/lung/2011/10/23/lux-lung-1-results-in-detail/
http://cancergrace.org/lung/2013/08/17/afatinib-for-acquired-resistance…
Combining Tarceva with a chemo agent such as Alimta is certainly a possibility, and Dr. West has written about that option here: http://cancergrace.org/lung/2012/06/19/chemo-with-or-without-ongoing-eg…
Although we can't tell you or your Mom what choice to make, given the uncertain benefit of Afatinib it is clearly not irrational to consider its significant toxicity in making a treatment choice.
JimC
Forum moderator
Reply # - March 6, 2014, 06:18 PM
Reply To: Alternative to Afatinib?
Jim has really done a good job pointing out the pros and cons of either choice. Personally, I'm not impressed by the published experience or my own clinical experience with Gilotrif (afatinib) after acquired resistance on Tarceva (erlotinib). My own practice has been to favor initiation of chemotherapy-based treatment, sometimes with ongoing Tarceva after progression, sometimes not, depending on how much progression there has been on Tarceva. The potential benefit of chemotherapy is significant in many patients, so I don't think it's necessarily desirable to focus overwhelmingly on EGFR-based treatments that are poorly established over well-established alternatives.
Good luck.
-Dr. West
Reply # - March 9, 2014, 05:04 PM
Reply To: Alternative to Afatinib?
Thank you Dr. West and Jim for your responses and information. Both posts were incredibly helpful. We have come to the conclusion to ask the oncologist to switch her treatment. Are there standard (chemo) treatment options after someone has progressed after Tarceva? If progression has been slow in the lungs but there have been a few bone mets over the last 3 years and now brain mets should Tarceva be continued in conjunction with a chemo? My mom had a new biopsy in Dec. 2013 which revealed the EGFR+ exon 19 but no additional resistant mutations(T790M,MET) were present.
Thank you for making this site possible. It is such a beacon when times of decision feel so overwhelming.
Reply # - March 9, 2014, 05:57 PM
Reply To: Alternative to Afatinib?
Hello,
The FDA has approved three drugs for second-line treatment of NSCLC, one of which is Tarceva. The other two are Taxotere (docetaxel) and Alimta (pemetrexed), either of which are usually appropriate choices. There are also other drugs which, though they have not been specifically approved in the second-line setting, are known to be active against NSCLC. These include gemcitabine and navelbine. There are also clinical trials of new drugs, some of which seek to overcome resistance to an EGFR TKI such as Tarceva.
There is a GRACE faq on treatment options after progression on an EGFR TKI: http://cancergrace.org/lung/2012/08/05/acquired-resistance-faq/
As Dr. West noted in the post referenced earlier in this thread, the question of whether to continue Tarceva and add chemo or just switch to chemo is one on which experts disagree. In addition, it can be a judgment call as far as how significant the progression is. I'm sorry that the GRACE faculty can't tell you which option to choose; that's a question for your mom's doctors, after a full evaluation of her situation and perhaps a discussion with her about the pros and cons of each approach.
JimC
Forum moderator
Reply # - March 9, 2014, 08:29 PM
Reply To: Alternative to Afatinib?
Thanks so much Jim. The link you provided contained the exact information I was looking for! I wanted to have a sense of what the standard options were after progression on a TKI. This will be my mom's third line treatment as she did 6 rounds of carbo/taxol right after she was first diagnosed which she did not respond to. Then she was put on Tarceva which she had been on for 8 years. Fingers crossed we can find a treatment that works and with fewer toxic side effects than Afatinib. Thanks Again!