Bone Metastases in Lung Cancer - 1268453

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bookend
Bone Metastases in Lung Cancer - 1268453

My mom was diagnosed with stage 4 lung cancer in July 2014 due the malignant plueral effusion. She's done some immunotheraphy and in October started Alitma. Her plueral effusion dried up in December. A number of her symptoms have gone away. Last week based on her CT scan a bone scan was ordered. There are spots on her pelvis, sacrum and ribs. She currently has no pain. She's been referred for radiation. She is considering not getting radiation because of the potential damage to her blood cells from radiating in the pelvic area. I'm worried about what might happen to her bones if she does not get radiation. I'm going with her to the radiology consult. Are there specific questions I should ask? When might she expect to start feeling pain? What are the risks if she chooses not to do radiation? What impact would radiation have on her red blood cells?

Thank you!

JimC
Hi bookend,

Hi bookend,

The main reasons to radiate bone mets are to alleviate pain and prevent fractures, especially in weight-bearing bones, including the pelvis. Since your mom is not experiencing pain, one question you may want to ask is whether, based on the scans, there appears to be imminent risk of fracture that requires intervention with radiation at this time. It would be hard to say when she might start to feel pain, because that would depend on how fast the bone lesions grow and the specifics of where they are located. For example a small bone met that impinges on a nerve might cause more pain than a larger one that does not.

High doses of radiation can damage the bone marrow function, but it's a question of balancing priorities. If troublesome bone mets are allowed to grow unchecked, there can be a great deal of pain and loss of function. As Dr. Creelan stated:

"[E]xcessive doses of pelvic radiation may impair your bone marrow’s reserve to handle traditional chemotherapy in the future. ... Most of the bone marrow in adults is in the hips, and so heavy doses of external beam radiation (>50 Gy) directly to this area can decrease your bone marrow reserve. It would be a shame if you could not tolerate chemotherapy in the future, simply because we zonked your bone marrow for a fanciful idea.

So without solid evidence, I would view the approach of ‘curative’ external beam radiation directly to the bilateral pelvic bones as short-sighted." - http://cancergrace.org/topic/nsclc-adeno-stage-iv-mets-to-hips-why-radia...

Please note his use of the term "excessive" - he is emphasizing the need to be conservative in the doses used.

Good luck.

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

kathleenf
Bookend,

Bookend,
it’s important that you are aware of another therapy platform that can be used to alleviate pain from bone mets, replacing, or in addition to radiation. It’s called magnetic resonance guide focused ultrasound (MRgFUS). If your mother is considering not getting radiation because of the potential damage, she may not have to. For example, my 78 year old cousin who got melanoma and was suffering from painful bones mets, got true pain relief that was achieved in a single session using no radiation. It’s a radiation free treatment. It reduced his pain significantly. I know that the company responsible for this technology is called INSIGHTEC (www.insightec.com) and I know that they have on their website information on all the locations where the treatment is available.
Good health to your mother!

JimC
Hi bookend,

Hi bookend,

GRACE's Dr. Blanchard mentioned this therapy in September 2014:

"A new technique to treat cancer pain is also under development. This uses MRI guidance to find the affected area and ultrasound waves to treat the pain (called MR guided focused ultrasound surgery or MRgFUS). In a small study of patients with advanced cancer, 64% of patients had an improvement in their pain compared with 20% in the placebo arm. (Hurwitz et al, JNCI March 2014). This procedure shows promise and needs more study." - http://cancergrace.org/cancer-treatments/2014/09/

As with any new therapy, the results of a small study are preliminary and only additional, more robust trials will determine how effective and safe this treatment proves to be.

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>

kathleenf
JimC,

JimC,

Thanks for your response. The actual study that you mentioned, is coming from the same company I mentioned in my initial response (INSIGHTEC) and this was actually the study that was the basis for the treatment’s FDA approval (which was granted in 2012) . If it’s FDA approved, why do you think that more robust trials are still needed?

From my personal perspective if a treatment is FDA approved that’s a testament to its efficacy and safety (by the way it’s CE approved as well, in Europe since 2007). As part of the research of the treatment that we have done when my cousin needed it, I also learned that the BCBS has reviewed the clinical evidence and has changed coverage policy in 12 states in the US to cover MRgFUS treatments of painful bone mets. So we figured If it’s good for the regulator and for private insurance companies, it worth trying.

kathleen

catdander
There is a trial going on of

There is a trial going on of this technique used for bone mets. The trials purpose is to evaluate chronic averse events due to the procedure. There have been ongoing problems for enough people who underwent this treatment to warrant further study. It is available in several institutes across the US and may be an option. The site locations can be found at the end of the link pasted below. Edited to add, Trials are one of the best places for excellent care and attention to detail.

"The purpose of this enhanced surveillance study ("ESS") is to collect information regarding chronic adverse events that are possibly related to the ExAblate® System ("ExAblate") that are received by InSightec ("InSightec") following PMA approval. This study will examine adverse events reported in patients undergoing the device procedure for the first two years of commercial experience. Other relevant data may be collected as well." https://clinicaltrials.gov/ct2/show/NCT01834937?term=Magnetic+Resonance+...

All best,
Janine

cards7up
The actual FDA approval is

The actual FDA approval is not for all bone mets. It says, "This imaging device is intended for pain palliation of metastatic bone cancer in patients for whom radiation therapy is not an alternative."
Take care, Judy
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApp...

catdander
I wonder if the fear of

I wonder if the fear of damage to bone marrow production is reason enough to use MRgFUS instead of opting out of any pain management treatment. That's my assumption.

Dr. West described some points to consider when deciding to use radiation to the pelvis, "There is some risk of radiating too much of the pelvis because that's where a lot of bone marrow is, and the marrow makes the blood cells that are regenerated after they're knocked down by chemotherapy. Radiation to a large portion of the pelvis can compromise the marrow enough that the rebound of blood counts after chemo can be problematic. But it's not unusual for patients to need and to receive radiation to areas of the pelvis, and most do very well with that." http://cancergrace.org/forums/index.php?topic=3814.0

kathleenf
I understand the concerns and

I understand the concerns and we had them too before my cousin went
through this treatment. I think it's good to know that this option is out
there, especially for people who are wary about chemo. I think the best
course of action here is to consult with your doctor about the treatment
and if it's appropriate for your specific case. We did just that and the
doctor asked for some time to research and read about this before he made
his recommendation. He did come back to us with some additional
information about the treatment and its safety profile (for example we
learned that it's a safe treatment with about 1/3% of adverse events which
are mostly skin burns and bone fractures). After such consultation, you
should be able to be in a better position to make a decision about what's
right for you.