Hello
I wanted to see if there are any doctors who would try the combination of carbo/alimta and Tarceva either together or intercalated for Stage 4 lung cancer that has EGFR+ mutation. My mother responded initially to Tagrisso as part of a treatment for possible Lepto carcinomatosis. Her CNS is fine now but she developed possible pneumonitis from tagrisso and they stopped it. Restarted Tarceva after 2 weeks. The next PET 2 months after Tarceva showed significant reduction in both size and activity of the primary lung mass but there was progression in lymph and pleura. They stopped Tarceva and started chemotherapy. After two weeks and one cycle of chemotherapy, there is now increasing size of the primary mass but the pleural effusion is gone. I am thinking that there are cells that are responding to chemo and some cells responding to Tarceva. Her oncologist says that the studies have shown no benefit with increase in toxicity with the combination but I have read some good data on PFS with the combination. What are your thoughts.
Thanks
Reply # - October 31, 2016, 08:51 AM
Hi nt99,
Hi nt99,
Toxicity would probably be the main objection to the combination in this instance (and some chemo regimens are tougher than others). Though there isn't clear data showing benefit from combining these treatments, an individual case may be a different story. It certainly is possible that portions of the cancer respond to one treatment but not the other.
One factor to note is that an increase in the size of a pleural effusion, by itself, is not usually considered strong evidence of progression warranting a change in treatment. So it really comes down to the extent of progression in the lymph nodes, and whether that is significant enough to stop Tarceva.
Also, although the majority of the response to chemo is seen in the first two cycles, after one cycle and only two weeks, it may be too early to make an accurate assessment of the efficacy of chemo.
JimC
Forum moderator
Reply # - October 31, 2016, 07:52 PM
Thank you. She had a
Thank you. She had a significant elevation in CEA and PET that showed progression in the pleura and nodes as well so there was progression but the primary tumor was reduced in size and in activity on the PET so there was definitely a mixed response. I have read that intercalated use of Tarceva and chemotherapy has given good response in some people. Her oncologist is reluctant to do it at this time. We will see what happens with the second dose of chemotherapy.
Reply # - October 31, 2016, 10:55 PM
That wouldn't be a typical
That wouldn't be a typical treatment plan and I've not heard any of our faculty mention its use.
Reply # - November 1, 2016, 09:20 AM
I was diagnosed with stage 4
I was diagnosed with stage 4 lung cancer with EGFR mutation in September 2010. My oncologist treated me with cisplatin/alimpta and 150 mg of Tarceva from the very beginning. I was NED by November 2010 and have had only 1 small progression which was treated with radiation. I continue to be NED and I will continue to take Tarceva (75mg) as long as it works. Everyone is different, but Tarceva and chemotherapy worked for me.
Reply # - November 3, 2016, 07:43 AM
Hi sceckhardt,
Hi sceckhardt,
Welcome to GRACE. It's great to hear that the combination therapy has worked so well for you. As you say, everyone is different, but it's terrific when you find something that works well for you, and I hope the great results continue for a very long time.
nt99,
There was a time when some groups of oncologists felt that it was best to continue an EGFR TKI even in the face of progression, adding another agent to bring the progression under control. That line of though isn't as prevalent, but it's an approach that can be tried. Several years ago, when my wife progressed on Tarceva, we added Alimta (to which she had responded well as first line therapy) and seemed to derive some benefit from it.
Of course, one of the problems when you combine therapies is that you don't know which of the agents isn't doing the heavy lifting, or if they're both contributing. The only way to find out is to discontinue one of them and see what happens.
JimC
Forum moderator
Reply # - November 5, 2016, 06:50 AM
Thank you for all your
Thank you for all your thoughts. I had read some small non-randomized studies that showed benefit in EGFR patient to continue TKI and give chemo. There was also a meta-analysis of multiple smaller trials that showed benefit. It was better when it was given in sequence and not exactly at the time of chemotherapy. Not sure what that meant exactly. My mom's oncologist is willing to try it in an effort to individualize but she says that data is not encouraging. She quoted the IMPRESS trial that used Iressa with Chemotherapy and it was a good randomized trial that showed no benefit. I still think that there are cells that definitely continue to respond to TKI and others that progress so it make sense that it would work at least for a while and maybe longer in some cases. In my mom's case, her primary tumor shrank with alot less activity on PET and her pleural mets increased. Even the PET report says "Mixed response" to therapy. After two weeks of no Tarceva and one dose of chemotherapy, CT showed new nodules in the right upper lobe and significant increase in the size of the primary tumor. ( She had a CT done prior starting the chemotherapy and then another one two weeks after because she got short of breath with a fever). Sometimes we have to think outside the box and look at patients individually. I am not sure what my mother's response to this treatment will be but we shall see.
I am a cardiologist and I do practice evidence based medicine most of the time but sometimes, individualized care works really well even if not standard therapy. Our evidence is as good as the last study that was done.
Thank you Sceckhardt and so glad that you are NED. I hope you continue to do well.
Reply # - November 6, 2016, 02:51 PM
nt99,
nt99,
From what I understand the idea of individualized care is more a norm in advanced cancer care than in most other health care planning.
I wonder if you've read/watched these discussions on partial progression on TKIs. They represent the newest thinking on the subject of progression. http://cancergrace.org/lung/tag/oligoprogression/
Best of luck to you and your mother,
Janine