Choose to delay treatment for stage 4 nsclc? - 1265938

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jilla
Choose to delay treatment for stage 4 nsclc? - 1265938

I am new to this site but thought I would ask for feedback. My dad,78 years old, diagnosed with nsclc poorly differentiated cells with 2 small (7mm) mets in liver in June as an incidental/accidental finding -he had a cough because of a pneumonia and they saw a mass on the other lung. Lung biopsy couldn't differentiate the type of cells. He finally had a PET scan and MRI about a week ago, and the oncologist said MRI showed several small lesions in the right cerebellum, the largest less than 5mm. We are waiting for an appointment with the radiation oncologist, however the oncologist said that he will likely need WBR. They did a 2nd US of the liver yesterday, which showed the liver lesions have not progressed in the 3 months since the initial CT/US. They hoped with the US they could also biopsy the liver to get more tissue than they did with the lung to be able to identify if there's a gene mutation, but the radiologist said the masses are too small to biopsy and it would be unsafe to try to do it. So prob he will have standard chemo when he starts.
My dad is very healthy and active. He smoked a little for 5 years in the 1960s then never again. No other medical history at all.
He is also completely symptom free from anything that you might expect - no cough/pain/shortness of breath/headaches/dizziness/weight loss. He feels great, which is why it's so hard to accept that he has cancer with mets. My question is would it ever be recommended to delay treatment -WBR and/or chemo- until symptoms develop? I am afraid of how side effects from any of these treatments will affect his great quality of life if his time is limited. Does it make sense at all to hold off on initiating treatment until there are any symptoms, and if none to rescan in a few months -and then start immediately once there is progression or symptoms arise? Or does he start immediately even tho his quality of life will be dramatically altered? Again, was first dx'd 3 months ago-it's been such a slow process

JimC
Hi jilla,

Hi jilla,

Welcome to GRACE. I'm glad to hear your dad has no symptoms, although that is often the case when Stage IV lung cancer is first diagnosed. When the cancer has already spread to the brain and liver, that means that there are cancer cells circulating throughout the bloodstream. They are too small to detect on scans, but they can form new metastases elsewhere in the body at any time. The further the cancer has spread, the more difficult it can be to treat, so normally you want t initiate systemic therapy in a timely fashion in an effort to eradicate not only the visible tumors but also those circulating tumor cells.

Also, though chemo can cause difficulties, untreated cancer can cause even more trouble.

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>

jilla
Thanks for your reply. It's

Thanks for your reply. It's frustrating that it's been over two months and we still don't have any kind of treatment plan- I know they really were hoping to get a better cell sample from a liver biopsy, but that doesn't look like it's going to happen. It sounds like they will want to do the WBR first, and then start chemo? They wouldn't do them both together, would they?

Dr West
While it's reasonable to

While it's reasonable to defer on treatment in asymptomatic patients with what appears to be a slowly growing cancer (and an approach I favor in most such patients), we don't favor this approach for brain metastases, since the brain leaves little room for growth before new symptoms emerge.

You can read more here:

http://cancergrace.org/lung/tag/indolent-lung-cancer/

http://cancergrace.org/lung/2006/12/06/the-risk-of-overtreating-bronchio...
(this article speaks about a specific type of lung cancer called BAC, but it applies to other indolent cancers)

Good luck.
-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

jilla
Dr. West,

Dr. West,
Thank you so much for your helpful reply and the links to your articles. Do you find that mets (eg to the liver, as in my dad's case) can also be quite indolent if it seems that the primary lung mass is so as well? In cases such as what I have described my dad's to be, do treatment approaches at times start with treating the brain mets only, and deferring chemo for the other mets? And SRS would not be an option because of the presence of several small cerebellar mets, correct? These are all questions that have constantly been revolving in my head since finding out about the brain mets three days ago. I am so concerned with my dad going from healthy and feeling fine to being a sick person as treatment begins...especially if this may not significantly improve his outcomes.
Thanks again for your opinions.

Dr West
Having liver metastases is

Having liver metastases is associated with a lower probability of the cancer being indolent than if the liver metastases were not present, but a cancer with liver metastases can still behave in an indolent fashion.

The radiation oncologist would need to comment on the appropriateness of stereotactic radiosurgery vs. whole brain radiation. WBR tends to be the clearly more appropriate choice for a large number of metastases.

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education