Wanted to get all your thoughts as I'm in a big dilemma and need to make a decision ASAP. I'm also in a foreign country so I cannot trust the doctors giving me mixed opinions.
I started Keytruda 3 weeks ago and I'm now experiencing brain swelling (I'm hoping it's because the drug is working) and one set of doctors want me on dexamethasone to reduce the swelling. He does not know what Keytruda is and dexa's impact on Keytruda.
Another doctor wants me to not take steroids as he thinks it would take away the efficacy of Keytruda. He wants us to do a treatment of Avastin and Keytruda. I have found conflicting info on Avastin. This doctor thinks it would reduce the swelling and continue Keytruda's effectiveness.
As I mentioned, I'm in a foreign country so I have not done any genetic marker / protein testing so I'm not even sure if Keytruda would work. But it is my last hope for the squamous cell esophageal cancer since I already underwent surgery last year. I believe the swelling is affecting my vision and some of my motor skills.
Any thoughts would be much appreciated.
-Michael
Reply # - January 18, 2016, 01:23 PM
Sorry, there are so many
Sorry, there are so many different aspects of this treatment decision to weigh, that none of us can say what "should" be done.
Many neurology doctors think of Avastin as a very expensive corticosteroid. Basically it mildly inhibits cerebral tumor bloodflow, which causes there to be less enhancement on imaging studies. So it seems reasonable to consider avastin in certain situations as an adjunct to reduce inflammation. That said, Avastin can also increase bleeding risk, so it can be dangerous in some settings.
Corticosteroids, like dexamethsome, shut down the internal activity of tumor reactive T-cells. At least for some other T-cell based cancer treatments, corticosteroids do impair the treatment response. So we avoid using corticosteroids like dexamethane in combination with PD1 inhibitors like Keytruda. In general, it is safe to use corticosteroids to treat severe side effects from PD1 inhibitors, but it is not wise to use them upfront.
In general, many doctors will treat the brain metastases with radiation (+/- steroids), and then start the PD1 inhibitor after the steroids have been tapered to off.