Conventional RT or SBRT (CyberKnife) - 1294230

24 posts / 0 new
Last post
lulu
Conventional RT or SBRT (CyberKnife) - 1294230

My Dad was diagnosed with stage IV NSCLC Adenocarcinoma back in Dec 2017. He has a couple lymph nodes metastasis and a small metastasis in his liver. He went through 4 cycles of chemo (Pemetrexed+Carboplatin+Bevacizumab) and now the tumor has gone down from 39*29mm to 32*21mm, lymph nodes metastasis seems to be gone and liver one is smaller. Now the onc recommended adding local therapy plus maintenance therapy, and we're struggling to make decisions about if we should go with SBRT (CyberKnife) or conventional RT. They both have pros and cons obviously. And my concern is if we go with SBRT, the lymph nodes might not be treated as what conventional RT would do (although some onc said that if the metastasis is not there for now, no need to treat it). Also, I have heard that there might be possibility that after SBRT treatment you could not use conventional RT in the future, is that true? Anyone has any suggestions regarding the pros/cons as for which treatment to go with? Thank you in advance.

Lulu

onthemark
My understanding is that

My understanding is that local control and survival is somewhat higher with SBRT and is considered now the standard of care but the main issue is that it is more convenient for the patient. It is also possible to re-irradiate with SBRT. This is an area that is currently under investigation by researchers. It is best to ask your doctors what they think but anyway here are some useful tidbits from the literature on re-irradiation in lung cancer.

"Salvage therapy with re-irradiation with SBRT technique for in-field recurrent lung tumors appears to be a effective and well-tolerated option for cautiously selected patients even centrally located. Our results suggest that, lower BED doses could still provide excellent LC for recurrent lung tumors in the previous RT field with an acceptable complication rate."

http://www.jto.org/article/S1556-0864(16)33268-3/fulltext

Also " Reirradiation (reRT) of thoracic malignancies may be an optimal strategy for providing definitive local control and offering a new chance of cure. Yet, retreatment with radiation therapy can be challenging for fear of excessive toxicities and the inability to safely deliver definitive (≥60 Gy) doses of reRT. However, with recent improvements in radiation delivery techniques and image-guidance, dose-escalation with reRT is possible and outcomes are encouraging. Here, we present a review of various radiation techniques, clinical outcomes and associated toxicities in patients with locoregionally recurrent NSCLC treated primarily with reRT."

http://jtd.amegroups.com/article/view/18319

JimC
Hi Lulu,

Hi Lulu,

Welcome to GRACE. onthemark has provided you with some great information, and it alludes to the most important factor in the decision: the location of the spots to be radiated (or possibly re-radiated in the future). That determination is made on a case by case basis by a patient's radiation oncologist, so it would be good to get as much detailed input from your Dad's rad onc in order to make an informed decision.

In the meantime, congratulations on the good response to treatment, and good luck with future therapy.

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>

lulu
Thank you very much onthemark

Thank you very much onthemark for all these great info. I will definitely look into them in details. For my Dad, he has peripheral CA,not central, and the doctor said there's no critical organ/tissues around his tumor, so it's relatively safe for SBRT. I sort of feel like SBRT is the better way to go, but the reason I was hesitating was because currently the hospital my Dad is receiving his treatment does not even have SBRT equipment (my Dad lives in China), and of course they would recommend conventional RT. But I did find another hospital in a different city offering cyber knife, so we will definitely check it out. Again, thank you for all the info, really appreciated.

lulu
Hi JimC,

Hi JimC,

Thank you for your kind words. Like I mentioned earlier, my Dad has peripheral CA, so hopefully that makes the whole radiation thing easier.

The doctor from the cyberknife centre already checked my Dad's images, and her suggestion was to only radiate the primary tumor on the left upper lung, because currently from the images the lymph nodes are back to normal (I guess chemo killed the LN mets), and for the tumor on the liver, she said it's too small and will be very hard to track its movement it during the treatment, so for now we could just wait and observe the one on the liver. I really hope this would be the right direction.

Lulu

catdander
Hi lulu and welcome to Grace.

Hi lulu and welcome to Grace. I'm so sorry about your father's diagnosis. I may be missing something but radiation treatment for metastatic nsclc is usually reserved for the lungs only if it were causing some obstruction or if it were the only known cancer left. But since there is other known cancer radiation could cause more damage than good. That's a conversation for both the medical and radiation oncologist whether radiation is appropriate or not. The goal is to live long and as well as possible and you want to save as much healthy lung tissue as possible.

All best,
Janine

lulu
Thank you very much Janine

Thank you very much Janine for your response. You actually have a very valid and good point. Me personally I wasn't thinking about radiation at all initially cause I knew the standard of care for metastatic stage IV NSCLC was just systemic therapy. The only reason we were considering RT is because our treating doctor said my Dad's case could be categorised as oligometastasis, so to apply local therapy could be an option here given his disease did not progress on chemo so far (I have read some researches done on this, but nothing has been confirmed or accepted as SOC).

I initially was thinking about switching him to immunotherapy if necessary, but from the second opinion I got from MGH, they don't recommend to immunotherapy unless the disease progresses. So now I feel like I'm really lost and don't know what to do...

JimC
Hi Lulu,

Hi Lulu,

I know exactly how you feel; most of us who have dealt with a cancer diagnosis, either our own or a loved one's, feel a helplessness that drives us to seek out the next option for fighting the disease. Quite understandably, we constantly want to be doing something to help eradicate the last vestiges of cancer.

But stage IV lung cancer usually doesn't work that way. When treatment results in significant shrinkage and stable disease, the best option may be...nothing. It's called watchful waiting, a period during which a doctor will closely monitor a patient with follow-up scans and physical examinations to check for indications that the cancer may be progressing. Watchful waiting can be a tough concept for both patients and their loved ones, but it does have significant advantages. The patient's body can recover from the rigors of treatment, and the patient can have some time in which life is a bit more "normal", without the constant roller coaster ride of therapy-induced side effects. And while most people tend to think that it's better to prevent progression than to address it when it happens, that's not what the clinical experience shows. As long as follow-up scans and physical exams are performed at relatively short intervals and new symptoms are reported promptly, progression can be addressed early.

Although there are more treatment options available to lung cancer patients than ever before, the number of those options is finite, so we like to get as much benefit from each of them as possible, and watchful waiting is one of the tools that can help achieve that goal. As Dr. West is fond of saying, treatment for stage IV disease should be a marathon, not a sprint.

It's at least worth discussing with your Dad and his oncologist.

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>

lulu
Hi JimC,

Hi JimC,

Thank you for your empathy, it’s very comforting. I’m a little desperate as I did want to be proactive. But Like Dr. West said it’s a marathon not a sprint and we don’t want him to be overly treated for sure.

To live with a lot of uncertainty and fear is just not easy. But that’s what I need to learn with my Dad’s situation I guess. Currently the doctor put him on maintenance chemo with Pemtrexed and Bevacizumab which is the standard of care, so it’s not a complete watchful wait, and I talked with my Dad yesterday, he’s more laid back, he said we’ll deal with it when it progresses. I’m holding my “unrealistic” wishful thoughts that it’ll never progress or at least progress much later than the median number.

Thank you again for all your kind words and suggestions.

Lulu

onthemark
I'm not sure what the best

I'm not sure what the best answers might be because you have to have all the facts and treat the whole person, but this is probably a common question now amongst lung cancer patients and something I have thought about if my cancer were to return.

I would be skeptical of irradiating only one of the remaining active sites if it is not causing problems and appears to be controlled by maintenance therapy. I think this is pretty consistent with what Jim and Janine have posted and what Dr. West has written on dealing with stage 4 lung cancer.

I certainly wouldn't go for radiating lymph nodes if there is no apparent active disease there. If any of these conditions were to change then the therapeutic response would also. It is still the case that the target for stage 4 lung cancer is not a cure but of prolonging the time that the patient is relatively well. With multi-modal therapy including immunotherapy some patients are living a long time with this illness and may end up dying of other things. So there is hope. Just about every week in the news a new study about lung cancer comes out. They are starting to point the way to real improvement that has not been seen in lung cancer for decades. On the other hand, survival statistics still have a long way to go to catch up with other cancers, whose research has historically been better funded.

I think a big difference now is that global pharma is starting to see a huge commercial opportunity in lung cancer treatments that didn't exist before.

lulu
Thank you onthemark for your

Thank you onthemark for your input. I do appreciate all these new studies which definitely bring hope to patients and families. But on the other hand, to be honest, sometimes I feel like overwhelmed as well with all these new treatments/studies/information. In the last few days, we've heard a lot of good news being announced at the AACR for the immunotherapy+chemo combo, and of course everyone is so excited. However, somehow, it did bring anxiety, at least for me, that what do I do if I already missed the 1st line treatment for the combo. With the Keynote 189 and iMPower 150 trail success with a much longer OS compared with chemo alone, I'm scared that for my Dad we already missed the opportunity which could be an implication for a shorter OS. Of course, every single individual is all different and all these numbers are just a reference, when it comes down to the individual, I guess it's more like either a 0% or a 100%.

Anyways, it's just some of my thoughts to share with you guys and it does feel better to talk to someone like you guys who totally get what I was thinking.

Again, thanks a lot for your input.

Lulu

onthemark
Hi Lulu,

Hi Lulu,

You are really knowledgable about all the studies. I am not clear to what extent the immunotherapy drugs are available in China. I would inquire directly with oncologists where you are. You might be able to get into a trial or it might be an option for standard of care after chemo.

lulu
Thank you onthemark. I did a

Thank you onthemark. I did a lot of research about all the treatments available for my Dad's situation. As for immunotherapy drugs, they're not officially launched in mainland China (both Keytruda and Opdivo have submitted the application to Chinese FDA, so hopefully they will be launched soon), however, a lot of patients actually go to HongKong and get the medication, they have almost everything that's been in the market for the states. I went to HongKong back in Feb and got some Keytruda as well, but haven't used them yet, sitting in the fridge now...

lulu
Hi JimC,

Hi JimC,

I have another quick question for you. Regarding the watchful wait approach, do you have any articles about it or maybe studies, anything related? The reason I'm asking is because currently in the NCCN (I believe ESMO as well) guideline, they do recommend to use pemetrexed (with or without bevacizumab) until disease progress, I'm just curious which approach would be a better option. Watchful wait or maintenance therapy all the way till disease progresses. If you could find anything and share it with me that'll be highly appreciated.

Thank you.

Lulu

onthemark
Hi Lulu,

Hi Lulu,

Those are all good questions and I'd like to know the answers as well. (I might try later when I can think of some good search terms in scholar.google.com)

This would also be so helpful information to others in China or other countries who might be on the 'cusp' of receiving immunotherapy treatment as standard of care in line with the most recent studies.

I would still discuss all the options with one or two oncologists involved directly in your father's treatment. There is always the question of best medical judgement for the care of a particular individual rather than the generic statistical best odds.

I don't know if any studies have been done of Keytruda as maintenance therapy with or without chemo and with or without targetted radiation for oligometastacise (sp?) as well. It's a complicated question too because each drug has its own side effects which have impact of quality of life long term.

JimC
Hi Lulu,

Hi Lulu,

The question of the relative value of maintenance therapy in general has been debated for a number of years, with no clear answer. It appears that the NCCN guideline regarding pemetrexed maintenance was downgraded a few years ago from category 2A to 2B (based on low-level data in either event), although the current guideline is unclear on that subject. It should be remembered that the guidelines describe therapies which are appropriate, based on either high- or low-level evidence, but in each situation there are a number of appropriate therapies. One of the options stated in the NCCN guideline for stable disease after first-line treatment is close observation (watchful waiting).

It's been difficult to determine the true value of maintenance therapy in clinical trials. An improvement in progression-free disease from maintenance therapy (which makes sense, since you're continuing to treat the disease and you would expect progression to occur at least somewhat later) doesn't necessarily translate to an improvement in overall survival, and patients in both of arms of such a trial often eventually receive the trial drug or other subsequent therapy, which clouds the picture. But there is one trial that showed an improvement in both PFS and OS, the PARAMOUNT trial, discussed by Dr. Socinski here. When the drug policy board (NICE) in Great Britain reviewed the evidence two years ago, this was still the only trial evidence available.

So either option is appropriate, and the choice involves both the art of oncology and the personal preferences of the patient.

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>

lulu
Hi onthemark,

Hi onthemark,

If you could find any useful info/studies, please share with me. Thank you.

Also, for now, even if we chose to go with maintenance therapy, we won't switch to immunotherapy, it'll be pemetrexed until the disease progresses, cause neither oncologist in China nor the States recommend to change treatment regimen as the current chemo is still working at this point in time. I guess for patients like my Dad who already accepted chemo alone (without immunotherapy) as first line treatment, they already missed the opportunity to use the combo as first line, and immunotherapy will be a valid option for second line treatment then.

It was very nice to have all these discussions with you guys here, both comforting and informational. Thanks for all suggestions and input.

Lulu

lulu
Hi JimC,

Hi JimC,

Like you said, I guess the debate has been on for years. So far, I did hear different voices too. One of the oncologist I talked to in China said he is not a strong believer in maintenance therapy, because the OS benefit is not huge (if it even exists) compare to the toxicity. Without maintenance, the quality of life could be higher at least for a couple months, and patient could get a break from the "routine" treatment. On the other hand, like you mentioned earlier, to choose the watchful waiting approach is hard for a lot of people, as we might feel so helpless and fearful of doing nothing. Without strong evidence in favor of neither one, it's all about different perspectives and preferences I guess.

I will definitely look into the studies you mentioned to get a bit more info.

As for the local therapy right now, probably we'll pass it for now. First of all, my Dad is not keen for it. Also, one oncologist mentioned that usually if patient has mets on the liver, it's hard to categorise it as oligometastasis, because most probably some other mets will come up and just not reflected in the images yet. I don't know how true this statement would be, but as my Dad is not interested in local therapy, at least not for now, so we'll respected his idea.

Thank you for all the info you provided.

Lulu

catdander
That sounds right Lulu,

That sounds right Lulu, oligomets aren't usually in the liver. Liver mets are usually thought to be fully metastatic. At any rate it would need to be locally treated to expect it to be eradicated. There really isn't a known best choice for using maintenance treatment and many oncologists let the patient guide the choice to forgo maintenance or not. Some people feel safer not stopping treatment and others want the break. The most important thing to remember if a break is taken is to scan often 6-12 weeks and contact the onc with new or worsening symptoms. This way you catch the progression early to start treatment asap. This is an approach many oncs feel is just a good (or better since you get a break) than continuing with maintenance.

lulu
Thank you for your response

Thank you for your response catdander. I will definitely talk with my Dad and ask her preference regarding maintenance therapy, and we will respect his choice and if he wants a break we will definitely closely monitor the tumor.

catdander
Your poodle looks comfy. Is

Your poodle looks comfy. Is it a pup? I have a redbone hound that gets that kind of comfy but I swear she sheds as much as my husky did. If she ever gets a dog it will be from the poodle family.

lulu
Yes, he loves our couch and

Yes, he loves our couch and beds, and gets really comfy. I got him when he was a puppy, but the picture was taken recently, he's 1.5 years now. Love him so much, cutest and sweetest thing ever, and I didn't even want a dog before, lol. Poodle doesn't shed much at all. The only time I would find his hair is when I wear black pants.

onthemark
Hi Lulu,

Hi Lulu,

"To live with a lot of uncertainty and fear is just not easy. But that’s what I need to learn with my Dad’s situation I guess."

This statement resonated with me and I would guess with many others who are facing similar life threatening situations either themselves or close family members. We want to do everything pro-actively possible and make some kinds of plans for the future. Watchful waiting is not the same thing as just waiting.

I would let go of your concern about missing out on the immunotherapy + chemo, clinical trial as first line therapy. No one knows what the outcome is going to be heading into a trial, so the evaluation of the information ex post facto is different than in real time.

I lost my thyroid function after one round in a clinical trial for a immunotherapy drug as adjuvant therapy and dropped out of the trial because I was concerned about what organ might be attacked next by the drug under consideration.

On the other hand once there is clear benefit that is tangible in real life, then the level of acceptable risk is higher. That is why most if not all new cancer drugs are first tested on metastatic patients.

lulu
Hi onthemark,

Hi onthemark,

I’m pretty sure a lot of patients and fainilies feel the same way as we did. There’s no easy route for this journey battling stage IV cancer. We all need to let go the fear or maybe just to live with it.

As for the immunotherapy, what’s been done was done, I could only look forward and hopefully my Dad could be stable as long as possible before we need to switch treatment regimen.

Thank you onthenark, enjoy the rest of your weekend!

Lulu