NSCLC squamous with EGFR - 1265684

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NSCLC squamous with EGFR - 1265684

I need some advice regarding the directions of my wife's cancer management. She was diagnosed stage IV Squamous lung carcinoma, positive EGFR mutations, on 27.05.14. She had a left upper lobe tumour of @6.7cm with mediastinal and pretracheal lymph nodes of various sizes. She also had a left chest wall inter-muscular well defined mass (since excised) that was the reason she sought medical attention. She is otherwise asymptomatic. She is a fifty two year old fit marathoner.
Management and Progress: she commenced oral TKI using Iressa 250mg daily since 10th June. Her primary left upper lobe mass has now shrunk to less than 10% of its original size and the mediastinal lymph nodes to 25% of original. There was no further metastasis elsewhere. The original plan as envisioned by the oncologists was to continue the oral TKI until progression or development of resistance. However last week our local oncologist advised surgery to preempt the development of resistance, this is much to our surprise, as she was only on medication for 11 weeks.
We consulted a cardio thoracic surgeon yesterday, and he strongly advised against surgery now, but maybe in three months time, if there's no evidence of any metastasis.
We are thus in a dilemma and torn between two differing advices. We welcome advice from anyone in a similar situation or had undergone surgery for stage 4 NSCLC after Tarceva or Iressa.

Reply To: NSCLC squamous with EGFR

Hello peterkin, Welcome to Grace. I very sorry your wife and you are suffering so. Your right that it's out of the normal thinking that surgery is called for in this setting though we may not have relevant info.

It's becoming normal practice to treat people with stage IV nsclc who have done well on a TKI focally (with radiation or surgery) when acquired resistance causes a tumor or 2 to show significant growth (or to mitigate suffering). As long as the TKI is working on its own and the person is doing well then we celebrate living life. A thoracotomy can cause long term pain and muscular skeletal problems, look no further than my husband as an example.

We look at stage IV treatment as a marathon ;) not a sprint; since there are a limited amount of tx options it's best to use them only when needed. Done with good surveillance and not over treating. Following is a blog post with an algorithm used by most nsclc specialists while treating those on TKIs or just plan ol indolent nsclc. http://cancergrace.org/lung/2013/01/23/acquired-resistance-algorithm/

I hope your wife does very well for a long long time,

Dr West
Reply To: NSCLC squamous with EGFR


To be clear, the local therapy that Janine is speaking about is becoming increasingly favored as an option for patients with a very localized area of progression in the setting of acquired resistance, but it's really not typical to favor "pre-emptive" surgery or radiation for areas that haven't shown evidence of progression. There are far more experts who favor the surgeon's thinking, in which surgery for a local area would only make sense if the following two conditions are met:

1) there is one focus or a very limited foci of progression (especially one focus)

2) enough time has elapsed to have some confidence that several other new areas of progression aren't far behind.

It really makes no sense to resect one area of disease if you don't know if that area will show progression, or if there are likely to be several other new areas of disease popping up within a few months. You can become increasingly confident that an area of progression is going to be an isolated area of progression if a good amount of time elapses with just one area growing and no other areas changing. The longer the interval of solitary progression, the more compelling the idea of doing surgery or focal radiation on the limited area of progressing disease.

Good luck.

-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