Does a sudden increase tumor require another biopsy - 1258310

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tracey59
Does a sudden increase tumor require another biopsy - 1258310

Dear Dr. West:

I just got my PETCT report last night. The main tumor on my upper right lung, which was 1.1x1.2x1.0 cm with SUV max 1.2 cm in the April 2013 report (it had been remained so since August 2012), suddenly increased to 1.4x2.9x2.2 cm, with SUV max=4.5 cm. I have been taking Iressa since 7th July 2012 and I have expected the occurrence of acquired resistance, but this significant increase still shocks me.

I was told that it usually takes 120 days (4 months) for adenocarcinoma to double its size; but my main tumor has increased by more than 150% in about 100 days. Does it indicate that the nature of the tumor has changed - i.e. it has become another type of cancer, or is it caused by T790M or something else? In order to know better, shall I request another biopsy when I am going to see my oncologist on Tuesday?

My oncologist talked about radiotherapy last time I saw her; but I was told that NSCLC does not response well to radiotherapy. Shall I try Tarceva first if there is no T790M mutation?

I am not sure if it is fair to ask you all these questions, but I am very worrying, and any advice would be deeply appreciated.

Many thanks and best wishes,

Tracey

56 Y never-smoker Asian female stage IV adenocarcinoma with exon 19 deletion

catdander
Reply To: Does a sudden increase tumor require another biopsy

Hi Tracey, I'm very sorry to know you've progressed on iressa. I don't know if the doctors will think it's an overly significant rate of growth since the size was very small to begin with. However this algorithm below shows the path doctor West takes in a process like yours. In a case where the progression is focal (only in one spot) he and many other lung cancer specialist are using treatment such as radiation (the reason radiation isn't usually used in stage IV lung cancer is it usually doesn't add benefit to the goals of treating, but that's changing with targeted drugs like iressa where it may indeed add benefit).

You've read about the possibility of tarceva being an option. I don't think it's been studied anymore since Dr. West wrote that post in 09. But the dosing of tarceva is a bit higher and may be a good option too.

Dr. West has this to say about repeat biopsy, "Also, please note my comment at the bottom about a repeat biopsy of the progressing lesion(s). I have mixed feelings about this. Though I definitely think this is and will continue to be a driver of our better understanding of the biology of lung cancer in general and acquired resistance specifically, I need to point out that most people won’t have an “actionable” result that leads to a practical improvement in our ability to manage the cancer or offer an effective alternative treatment — particularly if the person isn’t at a very large academic center with many trials of novel therapies. In addition, insurers may not pay for this intervention that isn’t part of an evidence-based standard of care right now, so there’s a change that a repeat biopsy could incur significant costs along with some small risks from the procedure itself."

This is the link to the algorithm that will be helpful in what you may want to talk to your doctor about on Tuesday. http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/

All best
Janine

Dr West
Reply To: Does a sudden increase tumor require another biopsy

I'm also sorry to hear about your progression. The idea that you should expect a particular doubling time is absolutely false. That 120 days may be a rough average, but the variability around it is incredible, anywhere from 30-40 days to more than 300 or even up to 600-800 days or more! Cancer can do anything, so variability is completely within the realm of what we see.

As for what to do, I provided a detailed discussion in the link Janine provided, but I can't get into specific recommendations for specific people when I'm not their doctor. Also as Janine noted, I think the value of a biopsy is debatable: the main value of it is to detect if the histology has changed to a small cell lung cancer, which is reported in up to about 14%, but I think many people (myself included) think that's a higher number than what we'd really see in broader experience, where I suspect it's under 10% if not under 5%. If a T790M mutation is detected, that's interesting, but when you ask "what do I do with this information, now that I know it?", the practical utility in terms of shaping further plans is very unclear to me (i.e., in most people, there is none).

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

dr. weiss
Reply To: Does a sudden increase tumor require another biopsy

The rate of cancer doubling is highly variable, and I wouldn't read too much into it. Either way, when cancer has clearly grown, you need to change your approach. You asked about radiation and mentioned a fear that NSCLC is not radiation sensitive. That's actually not true. NSCLC, while not typically as radiation sensitive as SCLC, can be fairly radiation sensitive. In particular, EGFR mutated lung cancer, including those with the T790M resistance mutation, can be very radiation sensitive; I've written about this before at http://cancergrace.org/lung/2012/04/03/radiation-to-address-cells-with-r...

That post also discusses the rationale for another approach that you asked about--radiating the spots of resistance followed by re-initation of TKI. This is an unproven, but promising approach. I am most excited about it when one or a small number of sites are progressing while the others are beautifully controlled on TKI. At ASCO 2012, we saw two posters retrospectively looking back on good treatment results with radiation followed by re-initation of TKI. Hopefully, my ongoing study will prospectively validate the approach (you need to have < 5 sites of progression to be allowed on).

The alternative approaches are clinical trials and chemotherapy. All have legitimate promise of controlling cancer.

tracey59
Reply To: Does a sudden increase tumor require another biopsy

Deer Janine, Dr. West and Dr. Weiss:

I am very grateful indeed for your advice. It gives me a clearer picture of what to plan for the next round of battle.

I have a total of seven tumors/nodules in my body, now the one on my neck is not visible, the main tumor and another nodule have grown, another nodule remains stable but its SUV has increased by about 300%, and the rest three nodules remain stable. So I have three sites of progression at the moment (which fits into Dr. Weiss's criteria). I will discuss with my doctor on Tuesday on what to do next.

Again, many thanks, and best wishes,

Tracey

catdander
Reply To: Does a sudden increase tumor require another biopsy

It may be helpful to copy some of the info you want to share with your doctor including references. It can go a long way in discussing treatment options. Some of these ideas and practices are new and not commonly known outside the lung cancer specialty field.

best of luck and let us know how things move forward,
Janine

tracey59
Reply To: Does a sudden increase tumor require another biopsy

Dear Janine:

It is very kind of you. Yes, I have read the links and copied the posts into my computer and will discuss alternatives with my oncologist tomorrow. I sure will let you know how things are moving.

Many thanks,

Tracey

Dr West
Reply To: Does a sudden increase tumor require another biopsy

Tracey,

Please just bear in mind that these are controversial questions where there are differences in recommendations even among lung cancer specialists. I wouldn't want to characterize the discussion as GRACE docs clearly advocating that repeat biopsies are necessary or that any one subsequent treatment strategy in acquired resistance can be considered a standard of care.

I hope you have a good discussion with your doctor.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

catdander
Reply To: Does a sudden increase tumor require another biopsy

Thanks Dr. West. I was thinking more along the lines of the blog posts linked to above that have clear discussion lines.

tracey59
Reply To: Does a sudden increase tumor require another biopsy

Dear all:

I talked to my oncologist this morning about my next treatment. I am going to take radiation to deal with the grown tumors and after that will take Tarceva. I do hope that Tarceva can help me to survive for a while before going for chemo.

Thank you all for your advice and kindness!

Tracey

catdander
Reply To: Does a sudden increase tumor require another biopsy

Best of luck Tracey.