NED: when do you stop treatment - 1256794

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NED: when do you stop treatment - 1256794

My Husband: DAvid, Dx in dec 2011 with stage 4 adenoca, ALK +, with 27mm lesion and pleural effusion.
treated with 4 cycles CArboplat/Alimta/Avastin with some shrinkage.
Another year of maintenance with Alimta/Avastin, with continued shrinkage
Today's scan : "scarring at site of previous spiculated mass. No current evidence of neoplasia."

Apart from praising God for a miracle, what are the implications?

Do we continue maintenance therapy?
or just Alimta?
or just Avastin?
if so for how long?
how often would you get scans done
If/when reoccurence would we need to rebiopsy?


certain spring
Reply To: NED: when do you stop treatment

This does not even approach an answer - just wanted to say hurrah for your husband and his amazing results.

Dr West
Reply To: NED: when do you stop treatment

As certain spring said, congratulations: this is a great problem to have. However, there's no evidence to answer such a question. My approach is to ask what is the least treatment needed to control the disease. This could include any of the following options:

1) taking a break from all treatment and jumping back in at some point when progression is seen.

2) dropping either agent and continuing with just one. I would say that there is more evidence of the value of ongoing Alimta (pemetrexed) than Avastin.

3) Continuing treatment on a less frequent schedule, such as every few weeks.

While there is no evidence to support any one of these ideas over another, there is reason to be wary about longitudinal side effects of years of these treatments, as very few patients on maintenance therapy trials have been followed this far out, and there could be side effect issues that emerge from years of ongoing therapy. Without any actual evidence to favor any choice over another, it's not possible to make a clear recommendation -- I individualize it to the patient and their own preferences and issues.

I typically do scans at least every 3-4 months while a patient is on ongoing chemotherapy. The longer someone goes while doing well, the more confident you can be that things aren't going to worsen quickly. But if you think someone needs ongoing treatment, I think that pretty much means that you also feel they need their disease monitored at least every 4 months. One exception would be an oral targeted therapy like Tarceva (erlotinib) or XALKORI (crizotinib), in which I may feel comfortable with patients doing very well on these for a year or more and may favor scans on an every 6 month basis, but I favor pretty regular scans if you're giving someone chemo in this setting.

As for biopsy, I can't see a value in it in this setting. If it was stage IV, you'd have to presume that there's still at least microscopic disease somewhere.

Good luck.

-Dr. West

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

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