max creatinine level for continued chemo. - 1252611

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cessna
max creatinine level for continued chemo. - 1252611

37 year-old female patient thriving phenominally well on Alimta (Pemetrexed). Unfortunately, her creatinine level has reached 1.74 and her oncologist threatens to stop Alimta (on eve of full tumor clearance) if it reaches 2.00. My question is, if she were your lung cancer patient nearing remission on second-line, single-agent Alimta, how far would you let the creatinine level rise - before you would feel forced to suspend the Alimta chemo?

Thanks kindly,
cessna

catdander
Reply To: max creatinine level for continued chemo.

I'm sorry to hear of the rising creatinine levels. In the discussion below there is mention of 1.9 cut off for entering a trial. There is also mention of lowing the dose as opposed to stopping. Also there is much discussion about permanent lose of kidney function and the need for dialysis.

http://cancergrace.org/forums/index.php?topic=9104.0

There really isn't "remission" in lung cancer so I'm not sure of what you're expecting from a scan that shows no tumor. In lung cancer once the cancer has moved into the blood stream or lymph system as is the case in stage 4 treatment is focused on a balance of cancer control and quality of life. There is no expectation that chemo can kill every cancer cell in the system.

It sounds like this young woman has this balance. A break from treatment might help to lower the creatinine level and allow her to move back on it when later.

I've read doctors describe stage 4 lung cancer treatment as a long marathon as opposed to a sprint; you want treatment to last long by keeping side effects at bay.

I will ask a doctor to give expert comment on your question. You should hear back within a day.

All best,
Janine
forum moderator

drpietanza
Reply To: max creatinine level for continued chemo.

Hi Cessna,

I have seen irreversible kidney damage from pemetrexed, especially when it has been given for a prolonged amount of time. In general, we do not like to give the drug if the patient has an abnormal creatinine. Further, it is not about the level of the creatinine, but about the "creatinine clearance", if this number goes to 45 or lower, then the drug cannot be cleared from the blood and there will be too many side effects from the drug - leading to mouth sores and a decrease in all of the blood counts. It does seem that her disease is under good control and we dont want to expose her to the potential risks of chemotherapy. Thus, now does seem to be a good time for a treatment break. She will need normal kidneys later for other chemotherapies or for clinical trials. Sometimes, the creatinine improves.

Good luck,
Cathy

watu
Reply To: max creatinine level for continued chemo.

Taxotere is mainly metabolized by the liver, so it should be a good option in case of renal inpairment.
My father has chronic insufficiency and usually has creatinine level at 2.5 and creatinine clearance at 33-35. He is currently having Taxotere with no impact on his kidney function.

Mike

cessna
Reply To: max creatinine level for continued chemo.

Thanks to all three of you. In the interest of brevity, I greatly abbreviated the situation. My daughter was diagnosed Feb. 2012 with stage 4a cervix cancer - deemed inoperable because of attachment to bladder and rectal walls with indistinct margins. During SOC treatment with cisplatin, Gemzar and lifetime dose of pelvic radiation - she suffered a dreadful metastasis to several "out-of-region" aortocaval lymph nodes. I realize cancer is not re-staged if it worsens, but it is worth pointing out that this out of region metastasis effectively made her the equivalent of stage 4b cervix cancer which is considered universally fatal - usually within 3 to 6 months.

I appealed to this lung cancer forum because Alimta is very familiar to lung cancer oncologists - but NOT to gyno. oncologists (or their patients like my daughter who can only receive it off-label). Just 7 Alimta cycles has worked so dramatically that my daughter no longer has the requisite "target tumor or lymph gland" needed to qualify for any clinical trial.

What do I expect from a complete tumor clearance? I'm keenly aware that metastatic cervix cancer is highly likely to recurr years later - probably because microscopic amounts of remaining cancer cells cannot be detected by even the best PET/CT scan. That said, if my daughter had not proved resistant to Cisplatin, she originally appeared to have a statistical 18-20% chance of surviving 5 years. Consequently, It is our hope that the astonishing scope & speed of her disease clearance with just 7 cycles of single-agent Alimta might possibly lead to her life being saved.

I deeply appreciate the details on creatinine clearance provided by Dr. Pietanza. THANKS! Finally, to my relief, I learned today that my daughter's oncologist has been known to permit creatinine levels to rise as high as 2.5 in some circumstances for some patients - before ordering a pause or break in chemo. You have all calmed my nerves a bit. Thanks so much, cessna

cessna
Reply To: max creatinine level for continued chemo.

Hi Dr. Pietanza,

I realize it's a quick & dirty method, but I've just calculated my daughter's creatinine clearance using the Cockcraft-Gault formula found on Wikipedia, and hers is currently 41 (using her most recent creatinine level of 1.74). The formula suggests that if she could gain 10% more body weight (13 lbs), she would reach your threshold value of 45 that's required to fully clear the chemo from her body - enabling her to stay on schedule.

Her protein & albumin levels are near the low-end of normal, so I wonder if taking "protein shakes" in an attempt to regain some of the 20 lbs. of weight she's lost might help her "bulk-up"? Her oncologist and chemo nurses say okay to that, but I read that protein tends to supress appetite, so I'd hate to see it be counterproductive to her weight.

I'd sure appreciate any suggestions!

Thanks kindly,
Cessna

catdander
Reply To: max creatinine level for continued chemo.

Cessna, my husband is already a very thin man before losing his appetite with cancer. At first I prepared high protein, high calorie shakes for him then he started drinking store bought ones. He will drink, still does, vanilla ensure brand "plus" shakes. It has 350 calories in 8ish ounces and also a heap (can't remember) of protein. I wasn't able to match those numbers with my homemade ones and I'm not sure but I think he likes them better. Publix, a grocery chain in my area used to make an identical knock off that was cheaper but they no longer carry them. Someone else might. Also cancer alone eats up a lot of protein so eating more is a good thing. Also protein usually comes with lots of calories.

hope this helps

cessna
Reply To: max creatinine level for continued chemo.

Hi Janine,

Your experience and comments about protein shakes are calming. In my own research, 95% of the posted info I've encountered online advocates (as do you) that protein shakes are okay for chemo patients. However, they don't distinguish between someone noodling along normally on chemo - and someone struggling beyond tolerable limits of creatinine and creatinine clearance. That's why I asked here. I knew I would encounter some advice more closely targeted to my daughter's situation.

After all, protein is also considered "hard on the kidneys". If some of a chemo patient's vital kidney functions are dangerously high and about to force a halt to life-saving chemo treatments, it makes the caretaker tremble. Furthermore, one reads that protein supresses appetite - which I'd hate to see happen to my daughter. That explains my pause for thought. However, my daughter's oncologist and her chemo nurses agree with you - so I'm off to Costco and Sam's Club to find some Ensure "Plus".

See how much you have helped?!

Thanks,
Cessna

catdander
Reply To: max creatinine level for continued chemo.

Well thanks but the oncologist and the nurses know a lot more than me.
Good luck.

Dr West
Reply To: max creatinine level for continued chemo.

We really can't get into specific recommendations for individual patients, but there are posts here on the site about managing appetite and weight loss. This tends to be a challenging issue, though, without treatments that are consistently remarkably effective.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

cessna
Reply To: max creatinine level for continued chemo.

Dr. West,

Yes, I understand that every patient is engulfed in his own incredibly complex situation - so specifics are beyond the scope of what I should ask here. Nevertheless, I've gleaned some real gems of info. on this forum because of the unusually detailed exchanges found here. If I'm careful to avoid jumping to conclusions, there's much to be learned! --- So thank you doctor, for the time you spend helping folks here!

- Cessna

Dr West
Reply To: max creatinine level for continued chemo.

Here's the link to a good summary discussion of the topic of weight loss and amangement options in cancer:

http://cancergrace.org/cancer-treatments/2009/02/16/acs-mgmt/

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education