[Please help] nsclc with plural effusion - 1288542

Thu, 09/08/2016 - 04:03

Hi, my father (68 years old) has been diagnosis with nsclc with plural effusion on his left lung on march 2016. There is a 4cm tumor on the upper lobe and metastasis to plural and also lymph node. Since April 2016, doctor drain the fluid and suggested carboplatin + taxol, just three week after first cycle (when we go for 2nd cycle), the fluid build up covering 70% of his left lung. Immediately doctor drain his fluid again and applied bleomycin, doctor decided carboplatin doesn't work, so my dad started cisplatin + gemcitabin. My dad manage to finish all 4 cycle, and did a CT scan on august 2016. Result shows the fluid maintain at 20%, tumor shrunk about 1cm+ (2cm++ now). Doctor mention cisplatin + gemcitabin has done its job well. Doctor now suggest to stop at 4th cycle due to the toxicity that my dad might not be able to tolerate if we give two more cycle.

My question is should we go for 2 more cycle of gem+cis or is it an option to stop treatment now?

Through research we found that there is this new drug call pembrolizumab, my dad have done the test and it shows 50% positive. Can I check if this new drug will be able to cure my father. This is rather expensive drug we need advise on this drug.

As of now, should we go for maintenance treatment or its an option to stop treatment for now and monitor?

Please help to advise as we are now have no direction, my father has stop chemotherapy for a month now. We worry day by day when it will relapse or further spread. Please let me know if I didn't point out my question clear and I apologize for my poor english. Thanks in advance for all advise.

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Hello naret,

Welcome to GRACE. I'm sorry to hear of your father's diagnosis. There is no need to apologize; you have communicated the details of his situation well.

It is common to stop first line, platinum-based chemotherapy after four cycles. Most of the response occurs in the first two cycles, with some shrinkage in the next two and not much after that. In addition, the platinum drugs are tough on bone marrow function, so you'd rather preserve that function so that future therapies can be tolerated.

There is no consensus on whether to continue treatment with a maintenance drug, or stop therapy, watching and waiting with periodic follow-up scans. Patients and their families often have a very understandable desire to be actively treating the cancer, but there isn't compelling evidence that maintenance therapy leads to better survival, and it's good to have a treatment break and let the body recover from first-line therapy, which can be stressful.

One point which has been stressed often by the GRACE faculty is that an increase in the size of a pleural effusion, by itself, is not strong evidence that lung cancer is progressing, and treatment decisions should not be made on the basis of that finding alone.

Immunotherapies such as pembrolizumab have shown great promise, including long-lasting responses for some patients. With stage IV lung cancer, we don't really speak in terms of cure, but rather seek a therapy (or series of therapies) that keeps the cancer under control for a long time. Part of that strategy is to get the maximum benefit from each treatment regimen, which can include the time off treatment. So unless the cancer is progressing waiting and watching, though admittedly stressful, may be the best choice.

I hope that your father's response to chemo lasts a long time. Please let us know if you have further questions.

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Hi thanks alot JimC for your kind advise. Can I check on below:

1. Is there a study shows how long my father can last without any treatment given?
2. is there other method that we can use to monitor the progression other than the fluid level.
3. Seeing that my dad had stop the treatment now, will the cancer spread to other part of the body or it will be the growing of tumor?
4. Usually for cases with plural effusion, what will doctor predict on his survival period.
5. Is there other treatment option that we can consider other than pembrolizumab or this is the best choice that we can consider? (My father have tested EGFR and ALK negative)

Thanks again for all advise given. Best wishes for all.


Hi narret,

There really isn't a study that can tell you what survival may be without treatment, as it really depends on the aggressiveness of the cancer. The response to treatment is a good indicator, as is how long it takes for progression to occur, and at what pace.

Follow-up scans will be examined to look for tumor growth and/or spread; either or both can occur when the cancer progressses. If the effusion increases at some point before a scheduled scan, that may prompt an earlier scan to see if the cancer is progressing.

Overall survival depends on the aggressiveness of the cancer and its response to treatment. Any doctor who gives you a specific time frame is only guessing, because the available statistics are based on the experience of large groups of patients, and they don't predict how a particular patient will fare.

In addition to immunotherapies, there are other standard chemo agents such as pemetrexed, docetaxel, gemcitabene, navelbine and others which could be used. In addition, despite the lack of an EGFR mutation, erlotinib has been shown to provide some benefit as a second-line treatment.

I hope that your father does not need additional treatment for a long time.

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Hi thanks again for the information. I guess what I can do now is to monitor closely for any symptom that may occur. I really hope God show mercy for this can at least remain under control for years. Thanks again for your advice and information. Best Wishes for all.