Benefits of extending chemo beyond 4-6 cycles? - 1259101

amd5
Posts:16

First time poster. Thanks to GRACE for providing a terrific resource for people to learn about cancer and ask questions too.

When I started chemo in June, the initial game plan was to undergo 4-6 cycles of chemo (Carbo, Taxol, Avastin), followed by Avastin for maintenance. My latest CT scan shows significant improvement in reducing the size and quantity of the lung cancer nodules in my right lung. The largest nodule, for example, was 5-6 mm. in May (while on Tarceva) and is now 3 mm. with the Carbo/Taxol/Avastin treatment.

For what it's worth, I'm doing so much better now than I was in May, as indicated by the CT scan, the drop in the CEA marker values, and the dramatic improvement in my overall well-being.

Last month, after the fifth chemo cycle, my oncologist at Swedish Medical Center suggested that we extend the chemo treatment that I'm on to 7 or 8 cycles, and possibly more, as I'm tolerating the chemo fairly well. My primary side effects so far appear to be reduced White Blood Counts (WBC) for two weeks after the chemo and some mild neuropathy (numbness and tingling) in my hands and feet.

In doing some research, I noticed a ASCO study done in 2009 (http://jco.ascopubs.org/content/27/20/3277.long) that indicates that patients who undergo extended treatment cycles live just two months longer.

Do the doctors here have a opinion on the benefits of extending chemo beyond 4-6 cycles for patients who are currently stable or improving? Would changing the cycle times from 3 weeks to 4 weeks help reduce the toxicity of the extended chemo while still benefiting the patient? Would going back to the original plan of just taking Avastin for maintenance be better?

Thanks for any information you can provide.

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Reply # - September 9, 2013, 08:33 AM

catdander
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Hello and welcome to Grace. Congratulations on doing so well on your first line treatment.
The doctors on Grace have stated many times that they maintain the 4-6 cycles of treatment with platinum then if there is response move on to maintenance or break until signs of progression. If there is no response or progression they usually move right into a second line treatment.

The reason as you probably know is the ever heightened risk of hypersensitivity to the platinum. The idea of taking it easy, like you're running a marathon and want to be able to withstand treatment for a long long time so be on the safe side and stop when the odds of harm start outweighing those of benefit. Studies have shown this approach works as well and very often better than full on sprint where you risk body hits that compromise not just quality but also longevity.

Perhaps you've already read this the understanding hasn't changed though after 4 years of being on Grace I certainly have come to understand it better. Dr. West states, "This standard of care is based in part on the premise that the incremental adverse effects may escalate faster than any incremental benefit for a platinum-based doublet. With cisplatin, cumulative nausea, fatigue, risk of significant kidney damage, neurotoxicity, and overall “platinum blues” tend to make treatment beyond 6 cycles infeasible and disproportionate to any potential added benefits of ongoing therapy." He then goes on to discuss maintenance treatments that may also be of interest because it suggests something other than avastin. http://cancergrace.org/lung/2011/12/24/beyond-4-cycles-1st-line/

The slight neuropathy you're feeling can become more of a problem as you move forward. The more your nerves remain irritated the more likely it becomes they won't reverse. Taxol and platinums are culprits here so a switch maintenance of alimta or gemcitabine may also be in order.

continued...

Reply # - September 9, 2013, 08:37 AM

catdander
Posts:

Lastly if you're in Seattle a 2nd opinion with Dr. West would be more helpful than a forum discussion. Actually a 2nd opinion with a lung cancer specialist at a research hospital is always a good idea at crosses in the road such as you're at now. This blog post is an excellent explanation of all the good reasons a 2nd opinion is good. http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide…

Didn't mean to be so long winded. I hope this helps but hesitate to ask for clarification or follow up questions.
Janine
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Reply # - September 9, 2013, 08:45 AM

catdander
Posts:

You'll need to add your info onto your "signature" to show up at the bottom of your posts. Found in the "forum profile" by clicking on your user name or little green forum profile button. The big brown/grey "PROFILE" is wordpress and doesn't have signature option.

Reply # - September 9, 2013, 07:02 PM

Dr West
Posts: 4735

It's true that there's a pretty clear consensus that 4-6 cycles is where the benefit of a platinum-based doublet maxes out, but that doesn't mean it's terrible to treat beyond that point. I personally don't, particularly with Taxol (paclitaxel), since neuropathy can really escalate quickly.

It's reasonable, though I don't think clearly optimal, to continue beyond 6 cycles of a doublet, but other options could include Avastin (bevacizumab) alone, adding a different chemo like Alimta (pemetrexed) to Avastin, just using Alimta, taking a break and resuming at progression, and potentially even switching to Tarceva (erlotinib). My perspective and recommendations really depend on the specifics of an individual patient's situation, though, depending on the tolerability of the treatment, the desire for a break, anxiety about progression, how their blood counts are holding up, and a few other factors. It's just not a "one size fits all" approach to say what is best, but in general, my approach is to recommend the least intensive therapy that I suspect will be needed to keep the disease under control for the next few months...and that sometimes even includes being off of treatment for a period.

-Dr. West

Reply # - September 13, 2013, 06:06 PM

amd5
Posts: 16

Dr. West and catdander: Thanks for your responses.

catdander: The oncologist that I'm seeing now at Swedish Medical Center in Colorado, is the result of a second opinion that I had in July. The second oncologist concurs with the first oncologist on the Carbo/Taxol/Avastin approach mentioned earlier. The oncology team at Swedish Medical is unique in that they discuss their patient cases every week so I'm getting the benefit of multiple doctors reviewing my case and giving their opinion on how they think I should be treated.

Next week, I'm scheduled for chemo cycle #6. Before we proceed, I do plan to ask about the toxicity of Taxol and Carbo, as I want to better understand the approach that my oncologist is taking in extending the chemo beyond the initial game plan of 4-6 cycles. I'll also be asking about the other options that Dr. West mentioned with Alimta, Avastin and Tarceva.

Dr. West: I did take Tarceva for six months up until May when I started showing signs of progression. Will Tarceva still work after a patient becomes resistant? Since I do have the EGFR mutation, is there an alternative to using a targeted drug like Tarceva? Can Tarceva or another targeted drug be given in combination with a chemo drug?

Thanks!

Reply # - September 13, 2013, 10:26 PM

Dr West
Posts: 4735

Your questions are very good, but the short answer is that we don't know what might be best for patients who have progressed after a prior good response on an EGFR inhibitor. Here's a good summary link of the concept of "acquired resistance":

http://cancergrace.org/lung/2012/08/05/acquired-resistance-faq/

There are MANY other things written or discussed in videos about concepts in acquired resistance, so I'd encourage you to search that term around the site and check out some of them.

Good luck.

-Dr. West

Reply # - September 19, 2013, 11:47 AM

amd5
Posts: 16

I did have my sixth cycle of chemo yesterday. I also had a lengthy discussion with my oncology nurse about the questions mentioned earlier. Because I am tolerating the chemo so well, my oncologist thinks that the benefits of extending the chemo for another 1-3 cycles may outweigh the toxicity risks. My blood work is being monitored every two weeks, as is any signs of neuropathy and any other potential side effects. We are hoping that treating the cancer aggressively with additional chemo cycles will kill the remaining microscopic cancer cells that we can't see. I would prefer to fight the cancer aggressively now while I am healthy enough to do so rather than buy myself just another year or two or three with the more conventional approaches.

Regarding my taking Tarceva again, my oncology nurse said that even though I have the EGFR mutation, my response with Tarceva was not really all that good overall. Taking it again would probably not be all that beneficial. In addition, in a number of different ways, I'm responding much better now with Carbo/Taxol/Avastin than I ever was doing on Tarceva.

I also inquired about taking Alimta. Since I am responding so well to the Carbo/Taxol/Avastin regimen, my oncologist wants me to stay on this regimen as long as possible and keep Alimta in reserve for a second-line treatment, if necessary.

I'm due for another CT scan in about two months so that should provide another opportunity soon to see how I'm doing and make any needed adjustments. Now that I have had many of my questions answered, I'm comfortable with proceeding with this new game plan.

I'll keep you posted on my progress!

Reply # - September 19, 2013, 07:00 PM

catdander
Posts:

amd5, I can only imagine how difficult it is to have to make these decisions but I know you'll feel good about it once it's made. How good it is that you've got them to make, congrats.

Keep up your good health and live life,
Janine

Reply # - November 28, 2013, 09:38 AM

amd5
Posts: 16

It's been a couple of months since I wrote about the extended chemo I was undergoing. I've since had another three cycles of Carbo, Taxol and Avastin -- making it a total of 9 cycles. After the sixth cycle, I had an incident of neutropenia (low WBC) so my oncologist subsequently reduced the dosage of Carbo and Taxol by 20%.

This week I had another CT scan after which my oncologist discussed my case with a weekly tumor board. Based upon the mostly favorable scan results, the doctors agreed that it was time for me to go into maintenance mode with Avastin and discontinue the Carbo and Taxol part of my regimen.

The one part of the CT scan that was concerning was that "a new low-attenuation liver lesion has developed in the left liver lobe medial segment measuring 10mm in diameter." My oncologist said that he wants to monitor the new lesion and reevaluate it after my next CT scan in three months. In my scan from three months ago, I also had two other liver lesions (one 16mm and the other 8mm) both of which are currently stable.

Some questions I thought of afterwards include the following: When a new liver lesion develops as mine did, do oncologists typically wait and monitor it for awhile or do they try to treat it before it progresses further? How are liver lesions in lung cancer patients typically treated? Over the next month, as I go in for various appointments, I'll try to get clarification on these questions but in the meantime, if someone here can provide some insights to my questions, I would greatly appreciate it.

Happy Thanksgiving, everyone!

Reply # - November 28, 2013, 01:12 PM

Dr West
Posts: 4735

Liver lesions are treated the same as any other metastatic lesions -- there isn't a special approach for metastatic lesions in liver vs. adrenal glands or other parts of the lung, etc.

It's reasonable to switch to a new treatment approach right away if there is convincing evidence of clinically significant progression, but there also isn't any clear incentive to rush into treatment changes if the progression is ambiguous or subtle. It's very reasonable to repeat imaging and clarify before making any treatment changes whether there's really progression.

Good luck.

-Dr. West

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