Poorly Differentiated stage IV NSCLC with EGFR+ and PDL=90

Wed, 01/22/2020 - 12:14


My mom (68y old) was diagnosed with poorly differentiated stage IV NSLCLC lung cancer with mets to liver, bones and brain almost 9 months ago. At the time of diagnosis and since the drs coudn't locate the tumor's primary sight right away, we did further testing + markers tests and she had TTF1 + as well as EGFR+ and PDL =90. 

She was put on 80mg/day Tagrisso as her first line treatment and showed excellent response the first three months (her tumor almost disappeared to the astonishement of all the drs..) then unforuntately showed progression after another 3 months. the DR now decided to stop tagrisso and put her on chemo (Alimta + Carboplatine).

I hope someone can help me answer the following:

- The dr said that since mom's cancer is poorly differentiated, it is an agressive type of cancer and that it was expected that she would show great response at the beginning to tagrisso but that she will also relapse quickly. does this mean she will do the same to chemo?

- since mom has EGFR+, i read that those patients with this type of mutation do not respond well to immunotherapy; my mom however has a very high PDL (=90). dr said that in her case it might be different and that he plans to use this after chemoresistence. what are your thoughts on this?

Thansk in advance


JanineT Forum …

Hi Ray,  Welcome to Grace.  I'm very sorry to know about your mom.  It's great that she responded so well to tagrisso. 


Progression on tagrisso is measured 2 ways.  First, if the progression appears systemically (pretty much in throughout all tumors) tagrisso would be discontinued and chemo could begin.  But sometimes progression (resistance to the TKI) is found to be only in one or 2 places while the rest of the cancer is otherwise kept in control by tagrisso.  If this is the case you might well continue tagrisso.  Continuing tagrisso is especially considered if the brain mets are staying under control.  If this is the case chemo could be added for the new tumors (side effects would need to be considered at this point) or if it's just one tumor radiation is considered and tagrisso is continued.  

Otherwise, alimta and carboplatin can be started.  People who are egfr positive often do very well on alimta for long time and with fewer side effects than most other chemo drugs.  There's an idiom, responders respond.  Meaning if you respond to one treatment it's more likely you'll respond to others.    


To your question about immunotherapy,  it's true that people with an egfr mutation don't respond well to immunotherapy even if there is a high pdl 1 reading.  But the real issue is that it will be dangerous to move from and immunotherapy to a tki, it can cause life-threatening pneumonitis.  So that's an important discussion to have before trying immunotherapy. 


  OncTalk 2019 is a long, over 2 hour video of our yearly live patient forum.  If I'm remember correctly this video covers all the topics you're asking about.  The table of contents is in the first moments of the video and again at around 1 hour 30 minutes, during the break.  It is a very new discussion so it has the latest thinking on targeted therapies and immunotherapy treatment.  Not all material will be relevant but you will find good info throughout if you have that time.


I hope this is helpful and please keep us up to date.

All the best,