NSCLC -Stage 4 -Squamous Cell - Treatment options & Suggestion - 1258870

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reply2stevejohn
NSCLC -Stage 4 -Squamous Cell - Treatment options & Suggestion - 1258870

Kudos to each of you especially for DOCTOR' who are pretty active and doing valuable contribution to this Forum which is helping & educating Newbie's like me...

My Dad (72 years) is diagnosed for Non-Small size Lung Cancer –Squamous Cell and probably looks like it’s in stage 4 and Inoperable as per First opinion..

We did Biospy & PETCT scan as of now (not any mutation test)

EXTRACT from PETCT Scan Conclusion:(Pls do provide your interpretation on serious of this specific case)

-Large homogenously enhancing peripheral mass lesion in the superior segment of left lower lobe with complete destruction of 6th Rib in the posterior aspect with chest wall invasion with mild cortical erosion of adjoining 5th & 7th Rib.
-Multiple enlarged mediastinal lymphadenopathy.
-Few pleural based tiny nodular lesion in right lobe. Recommend Direct comparison with previous imaging/follow-up to confirm stability.

As this Cancer was new beast for us and we were clueless on this disease, we went ahead with Onc suggestion as we didn't want to delay his treatment and went ahead with Chemo as First line of Treatment----GEMCARBO and first round was done just 3 days back. (not sure on effectiveness of GEMCARBO)

Onc's current Medical Plan is to have 3-4 GEMCARBO for my Dad and then do PET scan to understand the treatment effectiveness and decide next course of action.

Last 3 -4 days, I did spend lot of time in this Forum and did find tons of information to educate myself with various treatment options (Surgery,Radiation,Chemotherphy, ChemoRadition,Clincial Trials,Alternative medicines),Side effects for different options,different treatment options, Nutriation.....But very difficult to conclude what could be the right way of choosing medical path as the outcomes also varies widely with each options:

Though I know each of us different and react different for medication...I need your Valuable Advice/Options & Suggestion to decide on right medication path

JimC
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

reply2stevejohn,

Welcome to GRACE. I'm sorry to hear of your Dad's diagnosis, but I'm glad his oncologist has gotten him started on treatment. As Dr. Weiss has said "Gem/carbo is a standard therapy for squamous cell carcinoma of the lung." - http://cancergrace.org/forums/index.php?topic=4732.msg28616#msg28616

And although mutations are less likely with squamous cell carcinoma, they do occur. As GRACE forum moderator Janine (catdander) has written:

"It’s absolutely possible for a squamous only cell lung cancer to have the egfr mutation. certain spring is one such unusual example. Though this is still rather rare it does seem to happen maybe more often than first thought or at least not to be wholely dismissed. For example cs also has a non smoking history which is unusual too though still her cancer was tested more than once for type.

"Here is a new video Dr. West put out on the subject. http://cancergrace.org/topic/brief-video-on-my-changing-perspective-on-m... " - http://cancergrace.org/topic/anyone-with-squamous-cell-and-egfr-mutation...

In his reply to Janine's post, Dr. West said:

" [EGFR mutations are] probably in the range of 1-2% of patients with squamous cell NSCLC, so not common, but definitely possible. Many cancers show some heterogeneous characteristics, so it’s possible that many cases will have a mix of squamous and adenocarcinoma.

"As I mention in the video, we’re still limited by only really finding mutations where you look for them, so we can’t say that much about mutations in squamous cell NSCLC because we haven’t looked exhaustively enough to really know."

With that in mind, you may want to ask your Dad's oncologist about testing for EGFR and ALK mutations, for which there are established therapies.

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>

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Thans Jim for your suggestion on Mutation test..even if the chance of success is very limited, I would like to try all possible options.Let me check with my Onc.
One quick clarification..Does these theraphy run in parallel to other current treatment -Chemo or only one treatment at a time.

JimC
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Especially in first line treatment, they would be used sequentially. Later, if a patient has started to develop resistance to a targeted therapy, another drug may be added. Normally you would want to give the current therapy an opportunity to work before switching to something else. Some oncologists will switch as soon as a mutation is discovered, but most will wait to see if the current chemo is effective. There are a finite number of drugs available, so you want to get the maximum benefit from each.

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>

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Hoping to get some interpretation on the complexity of this specific case..

Dr West
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

I'd say that gemcitabine and carboplatin is a very appropriate first line therapy here, among the more common ones for advanced squamous NSCLC. As far as mutation testing is concerned, "driver mutations" do occur occasionally in squamous NSCLC, though rarely, and at this time it isn't the current standard of care to do molecular marker testing for squamous NSCLC. This isn't to say it's a bad idea, but it's not part of the standard management protocol at this time.

Do you have other specific questions? We don't do interpretation of scan reports and really can't just comment broadly about the overall management of a patient's care. However, if you have a defined, specific question, we can try to address it.

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

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Dr. West,

Thanks for suggestion and kind advice.....I was trying to understand the complexity since I did get Mixed opinion from First Opinion and Second Opinion , where the First Opinon Onc categorized it to Stage 4 and Second Opinion Onc categorized to Stage 3B...

a) Though as per my understanding the teatment options is more or else same doesn't matter whether it is Stage 3B/4 but probably the response time to treat this disease might vary depending on this Stage and survival duration time might also vary..Please do correct me, if I'm wrong in my understanding.
b) Also it makes huge difference when you have "Metastasis" state of cancer which as per my understanding "mediastinal lymphadenopathy" is also Metastasis state.
c) And also having "few pleural based tiny nodular lesion in right lobe" could be also Metastasis state.
d) Also does Radiation in any way help after First 4 rounds of GEMCARBO before going for PET scan to understand the effectiveness of First Line of Treatment.

Regards,
SteveJohn

catdander
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Hi SteveJohn,

I'm very sorry you dad has been diagnosed with advanced stage nsclc. I understand you are trying to find the info about nsclc so to make sure your dad is getting the best treatment. In fact that is why most people are here so we understand. I don't know that you've seen our library of informative blog posts and videos so I'll link you to a couple are so to get you started. Our search engine is very helpful though you may need to log out to access the results (depending on your browser). We also have several tabs and drop down menus that help navigate around the library.

Let me know if this is helpful and don't hesitate to follow up with more questions.

Janine
forum moderator

http://cancergrace.org/lung/2010/04/05/an-introduction-to-lung-cancer/
http://cancergrace.org/lung/2010/08/22/introduction-to-locally-advanced-...

The final answer about how to treat IIIB depends on the individual case. Sometimes a IIIB is so difficult and or dangerous to try to cure that it should be treated as stage IV. Though, if the radiation field is such that it won't be too much radiation then yes radiation should be on the table, again depending, sometimes more is too much. Without it there won't be a chance of cure.
I hope that makes sense, or I should say it probably won't until you've had a chance to digest a bit.

Dr West
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Having pleural-based nodules would put this in the range of metastatic disease (stage IV). There is really no value for radiation in stage IV disease except to treat specific issues like pain, local compressive symptoms, and a few very defined situations. In general, there isn't any role or value in pursuing radiation before chemo for stage IV NSCLC.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Catdander,

Thanks for your kind words and also Library link provided by you has very useful info for Newbie's like me to get deeper understanding of the disease -Dr Weiss and Dr Pinder has articulated pretty nicely using few analog which helps non-medico people like me to understand better..At times on few specific case, this staging determination its not clear in Black & White.

Regards,
SteveJohn

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Dr. West,

Thanks for your Analysis and input...Since I had Mixed opinion from two different Onc on my Dad's case...Stage 3B & Stage 4 ..Also I do recollect from reading in this Forum that at times for Stage 3B on few specific scenario, Concurrent Chemo-Radiation was suggested as it is relative effective when compared to Sequential Chemo Radiation. As treatment option can slightly change based on Stage 3B or 4 so wanted to confirm same. Once again, Thanks for analysis in making clear on staging and also your suggestion on possible treatment options.

Regards,
SteveJohn

carrigallen
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Having definite pleural cancer would make it Stage 4. However, I'm not sure that has been shown your specific case. To me, I am not confident callling the pleural nodule on the opposite chest a definite metastasis, without more context or information. Regardless, this sounds like an advanced lung cancer, and chemtherapy is an important part of treatment. If someone is fit and healthy enough, we will often consider radiation and chemotherapy at the same time for Stage 3B cancers, but this does have many adverse effects too. Good luck.

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Dr. Ben Creelan,

Thanks for your intervention and for your analysis..........IMHO, As I understand whether one is " Definitive Metastasis" state or Not can change bit of dynamics of the treatment and looks grey atm ...

Can you Help us what could be ways & means to conclude on this aspect on this specific case, In fact I did check with my Onc during first opinion but he told me that it's difficult to conclude not sure for this rational.
As told earlier , the first line treatment with GEMCARBO is initiated with first round...Do you suggest us to complete 3-4 round then go for PET scan and get more analysis on the Opposite side on pleural nodule (not sure whether Pathologist can throw light here since they earlier PETCT scan report was grey in their opinion on this aspect) or Please do suggest what other possible ways to determine same on Metastasis state.

Regards,
SteveJohn

catdander
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

SteveJohn, I'm sorry but we can't get involved with individual cases as well we can't make suggestions for individuals. It's against the law mostly because it's impossible to make those types of decisions without all the pertinent details of the case. Please read over our guidelines that explain these things. http://cancergrace.org/grace-discussion-forums#guidelines

I completely understand the need to make the right decisions here. As in the link above there is a difference in some cases of stage IIIB nsclc where treatment is based on trying to cure the person of cancer. Other stage IIIB and all of stage IV is treated to extend life and provide better quality of life.

An opinion at a large research center where there are lung cancer specialists is your best bet in receiving the most up to date accurate info. They are able to discuss cases as a team where lung cancer specialist medical onc, radiation onc, and surgeons meet to discuss specific cases. This link explains the many reasons why second (or third) opinions are important. http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide-...

I'm not asking you to stop trying to get information from us, on the contrary. We are here to help you understand so you can help your dad.

Janine

catdander
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Also it's very likely that the treatment your dad is getting now would be the same at this point whether curative or palliative; as you suggested

Dr West
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Yes, I agree with Janine. These situations can be difficult enough to interpret that they're debated even by the doctors directly involved -- and they're all looking at the images and may have all of the relevant details. As doctors not directly involved and without all of the information, we can't get into the individual case details and can't offer medical recommendations.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Janine & Dr-West,

Thanks for the pointers as such you can understand the ambiguity running in my mind as it was not clear in Black & White few aspects of this case as the opinion varied...That was one of the reason to go too specific to get advice from this respectful Doctors and Forum members..

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Thxs Dr. Spigel for your seminar where you had presented some trial stats related paxitaxal choice during Squamous Seminar by Dr Spigel...We decided to go with Abraxane (Albumin based Paxitaxol) and Cisplatine combination after our attempt with Gemcarbo where the tumor was stable during 3 rounds of initial GemCarbo.....Cisplatine was bit harsh during his first round of treatment on him where he run short of breathless and we switched to carboplatin along with Abraxane for second round and he is able to take it with out any side effects and we decided to continue with Abraxane and Carboplatin combo....And we are in weekly cycle and till date we have completed 6 weeks.......And we want to continue with this combination for next two rounds as he is able to takeAbraxane and Carboplatin combo with out any side effects..Does changing from Cisplatin with Carboplatin will impact in the result stats...

Dr West
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Carboplatin with Abraxane is really more studied than cisplatin/Abraxane for lung cancer. The best answer is that there hasn't been enough research on this question to know, but it's obviously most important to pursue the treatment that a person can actually tolerate. Though there is some research that suggests efficacy of cisplatin may be marginally more effective than carboplatin in advanced NSCLC, but nearly all lung cancer experts are very happy to give a carboplatin doublet in advanced NSCLC, especially if someone had trouble tolerating cisplatin previously. Given how much better studied the carboplatin/Abraxane combination is than cisplatin/Abraxane in lung cancer, and how minimal the difference in efficacy is likely to be (if any at all), I have personally only given Abraxane in combination with carboplatin when I've given it as a doublet, and I suspect most other lung cancer specialists would say the same thing.

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

reply2stevejohn
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

Dr West,

Thanks for your reply on sharing your experience....I have dumb question,the efficacy of treatment when using doublet like Carboplatin w.r.to Gemcarbo or Plaxitaxol is decided by Primary drug (Gemcitibin or plaxitaxol) or in Combination since we already attempted doublet with Carboplatin earlier.

Regards,
Steve

Dr West
Reply To: NSCLC -Stage 4 -Squamous Cell – Treatment options &

I'd have far less enthusiasm for returning to carboplatin in someone who has demonstrated significant progression on it previously. In general, I think that the value of restarting carboplatin would be very minimal, and the potential negative effects likely to exceed benefit, unless carboplatin was just stopped because a fixed number of cycles had been given (we often stop at 3-4 before or after surgery or around radiation, and 4-6 cycles as first line systemic therapy for advanced disease). If someone had progressed significantly on carboplatin previously, I tend to favor either single agent or a "non-platinum doublet" such as gemcitabine/Navelbine (vinorelbine) or gemcitabine with a taxane (such as Taxol (paclitaxel), Taxotere (docetaxel), or Abraxane (albumin-bound paclitaxel)). None of these doublets has a proven value over single agent chemo for previously treated patients, but it's reasonable to consider an individualized approach for specific patient situations.

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