Lung cancer inconclusive biopsy - 1249490

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costica
Reply To: Lung cancer inconclusive biopsy

Well, it was a general question in my replies and I simply tried to make it precise.

If, after chemo and Tarceva it seems that it was an OK response, more powerful in the lung, maybe less powerful in the liver mets, and the patient is willing to take a more aggressive treatment, what would be some sound approaches? I have seen here mentioned Tarceva + Alimta, for example. The blood tests appear also OK.

The answer of the doctor was to go with the default, and he will also try to ask another colleague. He admitted that he didn't see too many patients with good responses in lung cancer.

Thanks!

catdander
Reply To: Lung cancer inconclusive biopsy

Hi costica, How wonderful your mom is doing so well on tarceva! It's great to hear she is feeling well too. The good thing about tarceva is the side effects often calm down with time. I hope her fingers get better soon.

One of the tenets of treating stage IV lung cancer is to use as little treatment as is needed to keep the cancer stable.

Most doctors would be happy to stay the course when a patient is responding to a drug. As a matter of fact they are pretty darn happy when a treatment keeps lung cancer stable. Your mom is doing so well with tarceva alone it would be a shame to give her chemo on top of it that will almost definitely add difficult side effects.

When the cancer begins to grow while on tarceva (called acquired resistance or AR) some doctors will add chemo at that point. There is much written on the subject on Grace.

I hope your mom does well on tarceva alone for a very long time to come.

Janine

Dr West
Reply To: Lung cancer inconclusive biopsy

I do think it's terrific that she has responded so well, so Janine is right that congratulations are in order. I'm sorry for overlooking your more general question -- in truth, when I see a list of labs and extended quotations from a scan report, part of my brain shuts off because I just can't address these issues here. I missed a very appropriate question because it was buried in a lot of detail that we can't address.

From many of your prior comments, I've gotten a distinct sense that your mother finds the treatment with her current dose of Tarceva challenging, at least, even if tolerable. There is no evidence that adding anything to Tarceva will improve outcomes, so I think the most likely scenario is that it would increase side effects beyond the point of tolerability, for unclear or no benefit at all. I couldn't be less tempted to add something to the Tarceva in a patient who is doing well on it now.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

costica
Reply To: Lung cancer inconclusive biopsy

She went to a cardiologist (she has hypertension for many years, but she keeps it under control with a drug called atenolol). The cardiologist prescribed her pentoxifylline to improve peripheral blood flow (she still experiences numbness in hands and legs). However, he did not know if this drug has any possible effect on Tarceva.

Is it possible to comment on this (namely, from the experience of the doctors, are there any possible interactions between pentoxifylline, atenolol and Tarceva)? The cardiologist said that, if the drug interacts with Tarceva or there are suspicions that it might interact, he can prescribe another one.

Thanks!

catdander
Reply To: Lung cancer inconclusive biopsy

Hello costica, I hope your mom is feeling alright. I just wanted to let you know that I've contacted Dr. Walko, our oncology pharmacist to answer your question.

All best,
Janine

dr walko
Reply To: Lung cancer inconclusive biopsy

Costica,
Erlotinib would not be expected to interact with either of the drugs you mentioned (pentoxifylline or atenolol). Since erlotinib can interact with so much though it is always good to check!

Best wishes,
Dr. Walko

Christine M. Walko, PharmD, BCOP, FCCP
Personalized Medicine Specialist
Moffitt Cancer Center, Tampa, FL

costica
Reply To: Lung cancer inconclusive biopsy

Still no scan, I am so frightened.

The condition of my mother is good however, and she is active. For example, she bought a stationary bike this summer and bikes 3-5km per day. That is in addition to walking outside each day.

I want to ask something. I know that it's not uncommon that people on Tarceva eventually develop leptomeningeal disease because Tarceva does not penetrate the brain barrier. I also know that, when LMC appears, a last desperate measure is to use pulsed Tarceva. I was wondering: has anyone used pulsed Tarceva in order to prevent the onset of LMC? Is there any evidence for this (of course, I don't expect published studies, I mean some evidence)? Thanks.

JimC
Reply To: Lung cancer inconclusive biopsy

costica,

First, I think that although LMC may be showing up more often because patients are surviving longer, often due to targeted therapies such as Tarceva, I don't think it's common. It may seem that way here on GRACE because there is not much literature or discussion of LMC elsewhere, so those patients affected by it tend to turn to GRACE for information.

I have not read of pulsed Tarceva being used as a general strategy. One of the problems could be insurance coverage if it exceeds 30 doses per month. It is difficult enough to try to convince an insurance company to cover such a regimen in the context of LMC.

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>

catdander
Reply To: Lung cancer inconclusive biopsy

I agree Jim, another reason for not wanting to use more is when tarceva was studied, like all other cancer treatment drugs they escalate the dose on trial patients to the highest amount people can handle without causing too many side effects. That's how 150 mg/day was established.

Dr West
Reply To: Lung cancer inconclusive biopsy

I know of no lung cancer specialist who has ever considered pulsed Tarceva as a preventive measure. There is no evidence to support this, though there is essentially no evidence in the world to speak to the question.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

costica
Reply To: Lung cancer inconclusive biopsy

It looks that I have good news.

My mom had a CT scan two days ago: apparently everything is good, although there are unclear things.

For example, is it possible that, in the last scan in May, to have a liver lesion of 26/41/28 mm in segment 6, while in the recent scan she has no lesion in segment 6 but a lesion in segment 5 (17/33 mm). Is it reasonable to have one lesion in segment 6 disappear completely, and have a new lesion in segment 5 appear? Or it is more likely that there is a mistake somewhere, especially when they use roman numbers for segments (so 5 is V and 6 is VI)? The general pattern is a decrease for the other lesions.

The overall conclusion of the radiologist was "favorable evolution".

All blood tests are within the normal range. All. She didn't test though for CEA. LDH is normal (one year ago it was like 4 times the upper limit of the normal).

And now, 3 general questions.

She has pain in the liver from time to time, not very powerful. I was so afraid since I thought that the tumors grow and thus the liver gets larger, pressing the membrane. Well, it seems that the dimensions of the liver *are* normal. She is wondering what could cause those pains. All standard liver blood tests (inflammation & function) were performed, and everything came back normal.

She has a balanced diet, avoiding too many fats and fried meat, for example. She ponders if it would be better to avoid meat and milk products altogether. The milk is organic, the meat - not quite.

She also stopped exercising on her bike as she was concerned not to damage the liver because of
the effort. She thinks now about resuming it, since she felt so good after exercising. For your patients in similar condition, has it happened that liver pain increased because of moderate exercise?

Thanks.

catdander
Reply To: Lung cancer inconclusive biopsy

costica, So glad to hear your mom had such a good report.
There's a blog post on the subject of nutrition and cancer that may help further her and your understanding of what's best. Though it sounds she is already eating very well. Instead of taking meat off her diet completely she could just eat it 3 or 4 times a week. http://cancergrace.org/cancer-101/2010/09/03/what-is-an-optimal-diet-for...

As for the other questions I'll ask a doctor to comment.

All best,
Janine

Dr West
Reply To: Lung cancer inconclusive biopsy

I can't interpret the scan findings and wonder if there's a misinterpretation of the location in one of the scans so that the two reports are referring to the same lesion. It's quite common to have some transcription error or other typographical issue, as you suggested. A new liver lesion would be considered as progression and not concluded to be a favorable result.

I don't know why she would have pain in her liver. There are many potential causes of pain in the right upper quadrant of the abdomen, including gall bladder inflammation and other issues, aside from pain from liver metastases.

There is no good evidence that being on a restricted diet leads to better cancer outcomes or reduces pain, such as from metastases. It's certainly good to have a healthy, balanced diet, and most experts just favor trying to maintain your weight and not get too fancy on eating massive amounts of one kind of food or avoiding major food types.

Similarly, exercise is generally advisable. It makes sense to avoid activities that cause pain, but otherwise, it's encouraged and helpful, not to be avoided.

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 Gadgeel
Reply To: Lung cancer inconclusive biopsy

As always I agree with Dr. West.

I suspect there may be an error in the radiology report.

As far as the pain is concerned the only thing I can add to Dr. West's comments is that sometimes pain related to right pleural metastases occurs in the right upper abdomen and the right 'flank'. I have seen sometimes this pain misinterpreted as pain originating in the liver. Does your mother have pleural metastases?

I would strongly second what Dr. West says about nutrition. We have no evidence that specific diets help us shrink or control stage IV lung cancer. Maintaining weight, particularly muscle mass is important to keep the body healthy.

Hope this helps.

costica
Reply To: Lung cancer inconclusive biopsy

We'll try to clarify the radiologist report, but I'm pretty sure it is a mistake. He is an experienced radiologist, and he couldn't possibly mistook significant progression for shrinkage. Yes, for sure he dictated the results to a radiologist-in-training or a student, and he didn't typeset them himself.

No, my mother doesn't have pleural mets, and her lung is clear now. One hypothesis she thought is that, because of intestinal gases (she has some of these), her liver becomes compressed and thus a dull pain. She started to experience these pains recently, when her liver tumors have the lowest dimensions since diagnostic.

Regarding Tarceva, is this a common pattern: complete response in the lung, good response in the liver and modest response in the lymph nodes? Doesn't this show that the cancer cells, while traveling from the lung, also suffered some mutations, and thus they do not react so well to Tarceva as the cancerous lung cells?

Dr West
Reply To: Lung cancer inconclusive biopsy

There is no such thing as a typical pattern. Everyone has their own pattern, and there is routinely variability in responsiveness of the cancer more in some areas than others, presumable due to molecular heterogeneity, i.e. different patterns of molecular features in different areas of cancer.

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

costica
Reply To: Lung cancer inconclusive biopsy

It was a mistake, the tumor is in segments 5-6. It's only one. No progression for now.

I should be happy that the results are very good, but I cannot stop thinking that it will come a moment when Tarceva stops.

I'd like to know what are the most promising clinical trials running now in phase 3 for acquired resistance to EGFR inhibitors? It might be an option a trial with PD-1 versus docetaxel, yet my mother isn't so happy about such a thing: she still has peripheral neuropathy from paclitaxel, so, if she receives docetaxel, she won't be very happy. Also, the loss of hair has quite a significant impact, a constant reminder that she is sick.

By the way, in the case of such a trial, how is the randomization assured? Because, if you are required to go to hospital every two weeks, you know you got PD1, if you go every three weeks, it must be that you got the taxane.

She no longer has liver pains, she is active (PS 0/1), and she walks and exercises daily.

catdander
Reply To: Lung cancer inconclusive biopsy

If it's that obvious they're probably not trying to keep it secret. Below I copied clinical trials . org's glossary definition of Masking and the 3 types. It's likely that particular trial is open label.

Best of luck.

MASKING (or Blinding)
A clinical trial design strategy in which one or more parties involved with the trial, such as the investigator or participant, do not know which participants have been assigned which interventions. Types of masking include none Open label, Single blind masking, and Double blind masking.

DOUBLE BLIND MASKING
A type of masking in which two or more parties involved with the clinical trial do not know which participants have been assigned which interventions. Typically, this includes the investigator and participant.

OPEN LABEL
Describes a clinical trial in which masking is not used. That means that all parties involved with the trial know which participants have been assigned which interventions.

SINGLE GROUP DESIGN
Describes a clinical trial in which all participants receive the same intervention. One type of Intervention Model (Design).

http://clinicaltrials.gov/ct2/about-studies/glossary#single-blind-masking

Dr West
Reply To: Lung cancer inconclusive biopsy

Yes, it's open-label. They can't hide who's getting what, so they don't try to. The standard treatment is a very appropriate one with proven benefit, even if it's not the treatment that most people going into the study are hoping to get.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

costica
Reply To: Lung cancer inconclusive biopsy

Thank you!

I'd like to ask if there is a correlation between peripheral neuropathy on taxol and the one on docetaxel. More precisely, if you have numbness and tingling one year after finishing carbo + taxol, is it likely to get much worse on docetaxel?

Dr West
Reply To: Lung cancer inconclusive biopsy

Taxotere (docetaxel) tends to be less damaging in terms of neuropathy than Taxol (paclitaxel), but it can still lead to worsening of residual neuropathy from prior Taxol.

-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: Lung cancer inconclusive biopsy

Hi Costica, unfortunately both taxanes cause peripheral neuropathy so additional agitation can certainly cause additional pn.
I hope your mom doesn't have to deal with more.

Janine

Theres a lot written here on the subject. If you have trouble accessing search results try logging off grace first. We're working to fix this and other issues we want changed.

All best.

costica
Reply To: Lung cancer inconclusive biopsy

Well, I didn't post anything for a long time, but I come here every day, looking anxiously for trials for EGFR resistance ...

Right now my mother seems to do great, fully active, goes out and uses a bike to exercise daily. Very good mood, despite the occasional pain caused by fingernails while on Tarceva. She hasn't done a scan though from November and she is reluctant to do one in the near future. I know, I am so afraid, but I can't convince her ...

As for future options, there is a PDL-1 trial in her city, but there are some non-medical stupid issues. We'll see. I couldn't find any other trials.

Assuming progression on Tarceva after finishing Carbo + taxol like 16 months ago, in a similar case, would it be an option to do another round of chemo, plus or minus Tarceva?

Thanks!

JimC
Reply To: Lung cancer inconclusive biopsy

Hi costica,

It's great to hear that your mother is doing well and keeping active. Hopefully Tarceva will continue to be effective for her for a long time.

There is no consensus about whether to switch to chemo after progression or add it to Tarceva. With relatively slow progression, or progression in only one area, it is possible that some cancer cells are still sensitive to Tarceva while others are not. In such a case, the choice may be to continue Tarceva to control those cells still sensitive while adding chemo to treat those which are not. Dr. West has written about that question here: http://cancergrace.org/lung/2012/06/19/chemo-with-or-without-ongoing-egf...

Wishing your mother continued success with Tarceva.

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>

Dr West
Reply To: Lung cancer inconclusive biopsy

I believe you're asking about, in your mother's case, potentially going back on chemo after starting with it and then having a very nice and long response on Tarceva. Yes, that would be a very appropriate strategy, probably the most appealing one aside from consideration of a promising trial of a novel EGFR inhibitor with potentially significant efficacy in the setting of acquired resistance. It's basically analogous to just starting second or third line treatment in someone who doesn't have an EGFR mutation, so the leading options tend to be the ones that have a proven survival benefit, namely Taxotere (docetaxel) or Alimta (pemetrexed), the latter being appropriate only in the setting of a non-squamous cancer -- in your mother, either of these options would be appropriate, since she has an adenocarcinoma.

As you alluded to and Jim noted as well, it's unknown whether it's beneficial to continue the EGFR inhibitor after progression in someone with acquired resistance after a good response. Some experts do it, and others do not. We still await evidence from trials to give us evidence to answer that question.

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

costica
Reply To: Lung cancer inconclusive biopsy

Hi,

My mother finally had a CT-scan yesterday, and the results are not so good.

The report said favorable evolution for all the lesions she had when she was diagnosed. However there are three new lesions:

- 2 new nodules in her right lung, 15 x 12 x 10 mm and 8 x 6 x 8 mm
- 1 enlarged left axillary lymph node (13 x 13 mm).

The conclusion of the report was that the evolution is OK, but the new lesions must be followed up in the near future. She didn't meet with her oncologist yet.

The blood tests are all normal, except for an increase in NSE. At the diagnosis she had it 58, one year ago it was 14, now it's 148, and the normal range is 0 - 17 ng/ml.

I am familiar with the algorithm outlined here: http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/ and with other articles posted here for acquired resistance.

I'd like to ask, for similar cases, would you say that there is still evidence of some disease being suppressed by Tarceva and that the option you'd favor is adding chemo to Tarceva? I don't know though if Tarceva would be still approved for her, it's not the decision of her doctor.

She remains in good health for now, fully active and doing physical exercises, after her appearance you wouldn't think she will die soon ...

Unfortunately she did not want to talk with the doctors running the PDL-1 trial in her city, and now it's just too late I guess. There is no trial for new agents close to her (or her country), or I couldn't find them.

Any comments are more than welcome. Thanks!

JimC
Reply To: Lung cancer inconclusive biopsy

Hi costica,

Your previous posts indicate that your mother's cancer had appeared in her lungs, liver and bones, so it certainly seems that if the only current progression is the three new lesions you've described, then Tarceva is very likely continuing to control the remainder of the disease. Dr. West has often used the analogy of "bad brakes vs. no brakes" when describing such a situation... Tarceva may not be controlling all of the disease, but it is still effective for the most part in slowing it down. I would think that the algorithm's recommendation of adding chemo to Tarceva is something worth discussing with her 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>

Dr West
Reply To: Lung cancer inconclusive biopsy

I agree that it sounds like her cancer is still largely controlled by the EGFR inhibitor, so in such cases, as the algorithm illustrates, I usually continue it. The question is then whether progression is enough to warrant adding anything to it, whether local therapy (for very limited progression) or more diffuse. Of course, we can't make medical recommendations for people who aren't our patients, so the actual proposed plan for what to do next needs to come from her own doctor.

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

costica
Reply To: Lung cancer inconclusive biopsy

She luxated her ankle, and could only go to her doctor today. She tried a different approach now, she used the informations here and elsewhere to inquire her doctor about possible options "what about this? Or that?". The meeting went much much better, and her doctor was very open to suggestions.

So, she will continue Tarceva, no question about.

They rejected to add Docetaxel to Tarceva because of the side effects which overlap Tarceva's side effects and because Docetaxel is used in many clinical trials (some running in her city). Of course, they would have loved to add Alimta, but it needs special approval (because of its price), the same as Tarceva, and it is unlikely that my mom will receive both. So they decided to try Gemzar for now (most likely). If Tarceva stops working completely, they will do Alimta + platinum, and then maintenance Alimta (or register in a trial).

My questions:
1. does this sound like a reasonable plan, on par with what you offer to your patients with PS0?
2. are there any bad side-effects of this combination?
3. is it true that Alimta penetrates the brain barrier much better? Is this something that would make you choose Alimta over other options?

If it's not OK, we could buy Alimta, but my mom and her doctor thought that maybe it's better to do Alimta+platinum (likely cis) first (taking a doublet now, with Tarceva, looks too painful for her).

Thanks.

I know, the best options would have been AZD9291 or CO-1686, but after spending many hours trying to enroll her or to obtain the drugs as compassionate use, I had to give up. No compassionate use, of course. There are locations in Europe, not in her country though, and it's just impossible to travel there (language barrier, her medical insurance is valid only in Romania). It shouldn't be that hard to enroll in a trial, I say, when that trial could extend your life ...

JimC
Reply To: Lung cancer inconclusive biopsy

Hi costica,

There are a number of choices for second line chemotherapy for NSCLC. In the US, the FDA-approved drugs are Tarceva, Docetaxel (Taxotere) and Alimta, but others are used including Gemzar. Often the choice is one made after careful consideration of a particular patient's circumstances, such as those you mentioned - ability to tolerate side effects, cost and keeping trial options open.

As far as Gemzar's side effects, Dr. West has written:

"It’s typically a 30 minute infusion and, as a single agent, is often very well tolerated, mostly with fatigue and some modestly decreased blood counts, perhaps some mild hair thinning (patients comment on it more often than you’d notice anything from looking across a room), and not usually much nausea or vomiting, especially on its own.

“Results may vary”, and that’s especially true if it or any other anti-cancer therapy is given to someone who has been on many therapies previously, but it’s among the more favorable in the balance of efficacy vs. side effects for plenty of patients." - http://cancergrace.org/lung/topic/gemzar/#post-8322

As Dr. West said, each patient reacts differently to a drug, especially when it is used in a combination which is not so common as to be well-studied, such as Tarceva/Gemzar.

As far as Alimta crossing the blood brain barrier, Dr. West has written:

“It’s not very well studied, but the idea that chemotherapy can’t get into the brain because of the blood-brain barrier is oversimplified. There’s actually evidence that the response rate of metastases in the brain is in the same ballpark as that of measured disease outside of the brain:

http://cancergrace.org/lung/2007/10/24/chemo-for-brain-mets/

[continued in the next post]

<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>

JimC
Reply To: Lung cancer inconclusive biopsy

[continued from previous post]

"There have been some vague hints that Alimta (pemetrexed) and Camptosar (irinotecan) may be particularly effective for brain metastases, but frankly I’d say that the amount and quality of that evidence isn’t enough for me to be at all inclined to make clinical decisions on the basis of that work. There’s really no meaningful work to suggest that one lung cancer treatment is significantly more effective against brain metastases compared with others.”http://cancergrace.org/forums/index.php?topic=11255.msg92631#msg92631

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>

Dr West
Reply To: Lung cancer inconclusive biopsy

Jim summarized the same things I was thinking as I read your questions but before I saw his responses. Gemcitabine is a generally quite well tolerated agent, and I think it's a perfectly fine choice under the circumstances...where I would note that there is not any single best choice at all. Alimta (pemetrexed) would be an agent I'd favor at some point, but my perspective is that it likely matters relatively little when patients get the treatment, as long as they get access to it and have a fairly good performance status (vitality/energy level).

And as Jim's quote from me says, I think the issue of Alimta getting into the brain is wildly overstated compared with the actual evidence to support this concept, which is quite minimal. I think it's gotten so much traction in part because everyone desperately wants to have an answer about a chemo that gets into the brain, so the tiniest hint of encouraging information becomes etched in stone as if it's the word from God. But it's too premature and the evidence too scant to get very caught up in that conclusion.

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

costica
Reply To: Lung cancer inconclusive biopsy

Thanks!

I forgot a small technical question, her doctor is still pondering about as he didn't have patients in this situation.

When you give Tarceva & single-agent chemo (my mom will likely have Gemzar), do you withhold Tarceva the day before the infusion or so? She takes the Tarceva pill around 11pm, and she will have the infusion during the day, say 11am, so they are evenly spaced.

JimC
Reply To: Lung cancer inconclusive biopsy

Hi costica,

Holding the Tarceva around the time of a chemo infusion in an effort to avoid any negative interaction between the two follows the theory of pharmacodynamic separation, which is discussed by Dr. West here: http://cancergrace.org/lung/2007/08/13/pharmacodynamic-separation/ When my wife combined Tarceva and Alimta, her oncologist advised her to withhold Tarceva for a couple of days, and we had no problems.

More recently, Dr. West has said:

"I would say that there isn’t any compelling evidence of antagonism between Tarceva and most chemo, and with Alimta specifically, so I am not following an approach of pharmacodynamic separation. However, I think it’s a reasonable thing to do, and in fact I would say that there’s no clear best answer here. Many ideas are very reasonable, but I definitely recommend for some of my patients and continue to have several doing well on for a long time." - http://cancergrace.org/topic/possible-progression-and-possible-options#p...

Good luck with the new treatment regimen.

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>

costica
Reply To: Lung cancer inconclusive biopsy

Jim, how do you find things so well? I try to read here as much as possible, and ask the faculty only for confirmation/what I don't know/newer thoughts but I don't find those things as easily as you do. Some of the quotes you put here I found myself though, but not all. In particular, I wasn't able to locate anything from your last reply on my own.

JimC
Reply To: Lung cancer inconclusive biopsy

Hi costica,

I've been asked this before, and to tell the truth I don't know. But I have been using the GRACE site since July 2008 when my wife Liz was diagnosed with NSCLC, and I have a good memory for the many posts I've read over that period of time. So when I search, I have a good idea what I'm looking for, often a particular post by one of the faculty which I remember reading.

We appreciate that you make the effort to find answers in the archived posts, but if you don't find what you need, please continue to post your questions.

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>

Dr West
Reply To: Lung cancer inconclusive biopsy

For the record, I should say that NOBODY can find relevant information quite like Jim. Our other moderator, Janine, does an impressive job, better than me, even though I wrote a lot of the quoted content, but Jim's abilities in this regard are unparalleled.

As Jim said, it's great for you and others to try to find relevant information yourself before asking a question, but we're happy to try to help if you're not successful.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

costica
Reply To: Lung cancer inconclusive biopsy

Her doctor kind of changed his mind, fearing that Tarceva + chemotherapy is detrimental. He said that another option would be a trial with Afatinib (currently though there is no trial with Afatinib in her country on clinicaltrials.gov). That trial apparently requires no brain mets, so she must do another CT in 3 weeks or so.

My mother is simply terrified, she fears that the cancer will grow beyond control, reach into the head or worse. Not to say that there is a good chance that she won't be able to tolerate Afatinib or Afatinib won't work. There are 3 new lesions, one of about 1.5 cm. It seems to me that it would take too long to enroll into a clinical trial which isn't running right now in her city. The makers of Afatinib could also cancel the plans with no notice, it seems too risky to wait for a promise!

My questions:

1. what is the trial which studies Afatinib after resistance to Tarceva?

2. Her doctor would be very willing to see any studies which show that Tarceva + chemo is not detrimental. He asked if there are any NCCN guidelines for Tarceva + chemo.

I sent to her doctor the article

http://cancergrace.org/lung/2012/06/19/chemo-with-or-without-ongoing-egf...

pointing to the original abstract published in asco (and in a journal in 2013).

Are you aware of any other evidence?

Thanks!!

catdander
Reply To: Lung cancer inconclusive biopsy

I don't think there's any new evidence or data to show the safety of tarceva combined with chemo except that of the lung specialists who use this method daily in patients they believe to be healthy enough for it. I'm sorry but we can't know your mom's condition, how she performs on one of the drugs. There will certainly be at least side effects from each drug and often (and we just don't know/have significant data about tarceva plus chemo) but sometimes a drug combo create their own side effects.

Here is another post that speaks to what lung specialists are doing that includes, in some cases the combo. http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/

Does her oncologist have an idea of when afitinib might be available in Turkey outside of trials? http://cancergrace.org/lung/2013/07/30/now-that-afatinibs-approved-how-s...

All best,
Janine

Costica, I don't know where you're located, don't know that you are also in Turkey. Just in case I want to make sure you know about this upcoming event, http://cancergrace.org/acquired-resistance-patient-forum-september-6-2014

costica
Reply To: Lung cancer inconclusive biopsy

Her health condition is excellent, she exercises daily.

I don't know if anyone can make predictions when afatinib will be available outside trials, but it is quite known that it doesn't have a significant outcome after resistance to Tarceva appeared. It would also be a problem with its cost, besides its side effects (my mom barely deals with Tarceva in terms of rash and split fingernails).

That is worrying for me, the doctor puts his hopes into a trial for Afatinib which I can't even find on clinicaltrials.gov. Who knows how long it will take until my mom will be able to get that drug or combination (if she will be accepted into the trial). The lux-lung 4 trial appears to be completed, and I can't find similar trials. Lux-lung 5 apparently does not run in Romania.

He said he would not hesitate had there been written guidelines in NCCN that Tarceva + chemo is not detrimental. Unfortunately I think that such guidelines will be written long after the death of my mother...

Quoting dr. West from this thread: "There are studies that show that it is feasible to give chemotherapy together with Iressa or Tarceva, and patients with an EGFR mutation generally do well with that."

Any help locating those studies?

Dr West
Reply To: Lung cancer inconclusive biopsy

Here are a few articles that show favorable results when an EGFR TKI is administered concurrent with chemotherapy in EGFR mutation-positive patients:

http://jco.ascopubs.org/content/30/17/2063.abstract?sid=4b94f7c8-f255-45...

http://www.medsci.cn/webeditor/uploadfile/201307/20130713145118716.pdf

The available evidence shows that there is not much activity of afatinib as a single agent in the setting of acquired resistance to Tarceva.

http://cancergrace.org/lung/tag/lux-lung-1/

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

costica
Reply To: Lung cancer inconclusive biopsy

Thanks a lot for the articles! They were decisive in convincing her doctor. So she had a Gemzar infusion today, she will do another CT scan after 2 cycles. She continues Tarceva.

I know I asked this before, but ... if you see significant progression on Tarceva (like 3 new nodules), do you order an investigation for the brain *only* because of that? SRS is not readily available, there is one in the country, but one may spend months waiting in line. WBR is available, though it is a very old device.

I think I read here that usually patients with T790M experience one area of slow progression. If you have 3 new areas of progression, would you say that T790M is unlikely?

And something incredible: Astra Zeneca *does not* have any contact information (phone, email) of the centers running the trial for AZD9291 in Paris or Manchester. I know that many complain there are not enough patients enrolling in trials...

Thanks again.

catdander
Reply To: Lung cancer inconclusive biopsy

i'm working w/out keyboard at the moment. theres info here that may be helpful. http://www.slideshare.net/JackWestMD/10-key-asco-2014-presentations-in-l...

Dr West
Reply To: Lung cancer inconclusive biopsy

You don't order a new brain scan just because you see a few progressing lesions elsewhere in the body.

And I would say that the evidence on patterns of progression in relationship to mechanisms of acquired resistance, such as T790M, is definitely very weak. I would have absolutely no faith that we can presume that someone has a T790M mutation based on a clinical pattern.

-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: Lung cancer inconclusive biopsy

Hi, Here are 3 AZD9291 trials at least one of which is in paris and manchester. You should be able to find a phone number that will be helpful.
http://clinicaltrials.gov/ct2/results?term=AZD9291&recr=&rslt=&type=&con...

THE cancer conference of the year is this weekend and there will be much to read about online. The link in my previous post lists Dr. West's top ten lung cancer sessions he's most looking forward to to possibly affect change in treatment and care.

Hope you mom is feeling alright.
Janine

costica
Reply To: Lung cancer inconclusive biopsy

She had a CT yesterday. I'm kind of confused about the results.

In May the scan found two new lung lesions, the largest of 15x12x10 mm and one "left axillary adenopathy" of 13x13 mm. She added Gemzar to Tarceva. The recent scan found that the lung lesions are gone, but mentioned "bilateral axillary adenopathy" of maximum 11 mm. Everything else is shrinking or even disappearing (the report mentions that some lymph nodes which appeared abnormal until this CT, now they look normal).

NSE became normal, last time it was elevated. CEA was and it is normal. I don't know why they order these tests...

Is it possible that there is a transcription mistake and the previous CT scan in May didn't mention that the adenopathy was bilateral?

Assuming that bilateral adenopathy is a new lesion, does that mean that Gemzar is not working and must be discarded? She had 3 cycles, no side effects, the day after the last one she had some swelling of one leg and a red spot appeared. She is aware of the suggestions of Dr. Lacouture posted here, things went back to normal in two days.

Catdander, unfortunately the AZD or Clovis trials are out of her reach (bureaucratic reasons).

Thanks!

JimC
Reply To: Lung cancer inconclusive biopsy

Hi costica,

This is something to discuss with her oncologist, who can pull up both sets of CT images and compare them. If he or she needs assistance to interpret the scans, he can query the radiologist(s).

After clarifying the scan results, you can discuss whether a treatment change needs to be made.

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>

catdander
Reply To: Lung cancer inconclusive biopsy

As Jim said checking with the doc is the best way to really know what the scans mean. Too your post from last scan suggests adenopathy in both lungs/bilateral so I'd not assume anything until you have a chance to talk to your mom's onc.
I'm sorry about the bureaucracy it can really bogs things down.

costica
Reply To: Lung cancer inconclusive biopsy

Her oncologist does not examine any scans, and does not query the radiologist. I guess one thing is the lack of time, usually they have too many patients.

JimC
Reply To: Lung cancer inconclusive biopsy

I don't know what to make of that, but somehow her oncologist would need to have a clear understanding of the scan results in order to determine further treatment. The GRACE faculty could only guess at what those scan results represent.

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>

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