Local therapies for metastatic NSCLC while on Osmirtinib

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Garth
Local therapies for metastatic NSCLC while on Osmirtinib

Hi. I listened to a panel discussion on Saturday Nov 10, led by Dr Jack West, on local therapies for oligo-progression or oligo-metastatic disease when a systemic therapy like Tagrisso is on place and working. The panel talked about radiation and surgery options. They did not mention internal radiation treatments like SIRT radio-embolization or radio-frequency ablation. 

I am in exactly the position described and I will most likely have one of these procedures on my liver shortly. 

I'm just wondering if Dr West or the other panelists had any comment on the utility of internal radiation treatments for localized progression. 

Thank you. 

JanineT Forum M...
Hi Garth,I'm not on the panel

Hi Garth,

I'm not on the panel but I think I can help.  These types of radiation are often employed for liver metastases but not usually in other parts of the body where you normally find lung mets.  I imagine the panelists didn't leave them out on purpose but more of an oversite since it's pretty specific use in the liver.  For the type of progression where local therapy works well (as in what you've described), it doesn't really matter what type of treatment but whether it's a good match for the type and placement of the target. Are you leaning towards sirt treatments for the liver met?  

I hope you do well with your treatment.

All best,

Janine

Garth
Hi Janine. Right now the

Hi Janine. Right now the doctor is leaning toward SIRT or radio ablation for the liver met depending on my PET scan today. He's an interventional radiologist so hopefully there's no bias. I really don't know which I'm leaning toward. Just want to consider everything, including proton therapy and SBRT. 

Dr West
Protons today are still more sizzle than steak.

Radiation approaches like standard “3D-conformal radiation” or proton beam are not as commonly used for liver lesions as the approaches you mentioned, which are more frequently used for brain, lung, or bone lesions, though a radiation oncologist would need to speak to the relative strength of these techniques over SIRT (selective internal radiation therapy) or RFA (radio frequency ablation) for a liver lesion, which are more frequently used options for the liver.  

Protons are newer, and protons are heavily marketed, but there is no clinical evidence showing that protons are better in metastatic lung cancer or prostate cancer or breast cancer or nearly all other adult cancers. Dr. Mehta made the point that protons have the potential to be better, but they don’t have enough sophisticated software support and experience to show that right now.  Protons are a bit like having a very expensive, fancy new phone with its own operating system, but there are still very few apps for it. That’s not clearly better than the current standard with a ton of apps and users and far more experience. Moreover, it’s not clearly the case that you can actually do more and do things better than with a good current phone and lots of apps and experience. Protons are like talking about the amazing technical specs of a phone, which is something easy to market, but does it actually lead to a better experience? Marketing of protons is based on the innuendo of what it might be able to do, but people marketing protons can’t highlight the better results, because there are no demonstrated better results in any common adult cancer.  And there’s a lot of marketing because it costs a ton to make a proton facility, so you need to market protons heavily to consumers, hoping they’ll be gullible enough to not ask for clinical evidence, because proton beam therapy evidence doesn’t sell itself...

This isn’t to say that proton beam therapy is inferior. It’s certainly comparably good, but in the absence of evidence to show it’s better, it is just a far more expensive platform that should be presumed to be no better than standard radiation. Dr. Mehta made the point that it may prove to be better in the future, and with time the technology is also likely to be more cost effective. In this respect, it’s like saying that the price of a new phone and operating system need to come down, and we need more time, before it becomes common enough to have the users and apps to make it attractive and broadly useful.

Good luck.

-Dr. West

 

 

 

Garth
Going with SIRT

Thanks for the reply Dr West. I've talked with my oncologist and an interventional radiologist here at MSKCC.  Going with their advice I'm going to proceed with Y-90 SIRT. We have a mapping procedure set up for this Friday. The way it was explained, this is the best procedure for the liver and this specific tumor, which is not spherical and has somewhat irregular margins. The protons, while precise, would need to target a large area to get the whole tumor and a margin. It seems like a better bet to target the blood supply feeding the whole tumor with glass Y-90 seeds. 

Thanks again. 

Jim C Forum Mod...
Jim C Forum Moderator's picture
Going with SIRT

Hi Garth,

Glad you were able to have good conversations with your doctors and develop a solid plan for treatment. Good luck, and we look forward to a positive status report filled with good news!

Jim C Forum Moderator 

 

JanineT Forum M...
Good to know you have a solid plan

Hi Garth,

I know you're in good hands at MSK and look forward to hearing about good results.

Janine