My mom's lung cancer (NSCLC) responds well to Tarceva but it appears her spinal bone mets has spread.
Chest CT in 11/2014 showed the primary mass has reduced in size. But MRI 1/20/15 showed new compression fracture in T9. Upon reviewing MRI radiologist believed there was "likely" new mets in T9.
1. Is it possible Tarceva is losing effectiveness and cancer has progressed?
2. What options can we pursue?
Thanks for your help.
1. My mom (82yr old non smoker) diagnosed Jan 2014 with Stage 4 NSCLC with mets to T10. PET scan showed mass in anterior right upper lobe 3.6cm x 4.7cm x 4cm
2. Mar 2014 - Cyberknife to T10
3. April 2014 - 1.5 cycle of Carbo / Gemzar before finding out EGFR+. Stopped Chemo.
4. Late April 2014 - Started 150mg Tarceva
5. May 2014 - Spinal MRI, condition stable
6. July 2014 - Reduced Tarceva to 100mg due to side effect.
7. July 15 2014 - Chest CT, tumor in right lung reduced in size
8. Oct 1 2014 - Spinal MRI, compression fracture noted on T11
9. Nov 2014 - chest CT, right upper lobe mass reduced to 1.7cm to 1.3cm
10. Dec 2014 - started Zometa 3mg
10. Jan 20 2015 - Spinal MRI, compression fracture noted in T9
Thu, 02/05/2015 - 10:22
Welcome to GRACE. It's not at all unusual to have what's know as a "mixed response" to treatment, in which some areas of disease respond while others progress. It's possible that is what is happening here, although it could be that there were metastases to the spine from the outset and that the bones have continued to deteriorate over time.
Although systemic treatments (such as chemo or the targeted therapy your mom has been receiving) can be effective against the cancer wherever in the body it may appear, if bone mets cause fractures and/or pain they are usually treated with radiation, because it can provide relatively quick relief from pain.
Her doctor should be able to help make a determination whether there is significant enough progression to warrant stopping Tarceva, or if the progression is slow enough, to continue for the time being. If it's time to change treatment, the options would be either standard chemotherapy drugs or a clinical trial of a new drug which targets acquired resistance to an EGFR TKI such as Tarceva. Her doctor may be able to recommend a trial and you can find a wealth of information here on GRACE if you search for "acquired resistance." You may want to start with the extensive information here.
As far as standard chemo drugs, in the U.S. the FDA has approved three drugs for second line treatment. Aside from Tarceva, the remaining choices are pemetrexed (Alimta) and docetaxel (Taxotere). You can read about second line treatment choices in Dr. West's post here, along with the links provided at the end of that post.
My best to your mom and to you. Please let us know if you have further questions.
Thu, 02/05/2015 - 10:24
Hi Wilson, I'm so sorry your mom is going through these awful problems. It is possible that tarceva is losing its efficacy in just one area known as acquired resistance. You can learn about it in the link below as well as the links following the discussion. If the progression is local it's possible to do local treatment such as radiation. A question you may want to discuss with her team is, is it possible that the compression fracture is due to the effects of prior harm (before tarceva)? That's a question for a neuro-spine specialist.
Thu, 02/05/2015 - 10:42
Thanks for the reply.
Mom did have mets to T10 at onset and received Cyberknife on T10 in March 2014.
I am following the T790M trials (AZD9291 and CO-1686). We consulted with Dr Ou at UCI. He informed us of acquired resistance and the trials
A neurosurgeon planned her cyberknife treatment in March 2014. We did followup with him. We are asking her doctors to discuss and reach a conclusion. She is seeing multiple specialists in different offices rather than a hospital or univertiy cancer center with a medical panel. These specialists don't communicate well enough and it is very frustrating to us.
Thu, 02/05/2015 - 13:04
Is there a way you can help the communication among the doctors?...a file, online case history or one central doctor who will take responsibility for the whole shebang. It's very important that everyone is in the know, Usually a medical oncologist takes that role. Often doctors collaborate even when they aren't in the same center. Perhaps you can help with the process by speaking with the med onc's team.