Progression on Gemzar - 1260435

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Progression on Gemzar - 1260435

My wife’s CT scan last week indicated an increase in size of nodules in both lungs. The two representative examples mentioned were a nodule increasing from 7mm to 11mm and another 3mm to 6mm. The radiologist stated that “innumerable nodules in both lungs have shown a comparable increase in size”. In addition, this CT scan showed pericardial fluid around the base of the heart which is new from previous scans (no symptoms yet). She was switched from Alimta to Gemzar in August with her last Alimta infusion 7/1/13 due to recurring pleural infusions and a mass in lower left lung (site of originating tumor). VATS surgery 7/17/13 indicated that this mass was likely due to significant scar tissue and pathology reports came back benign for all left lung tissue removed as well as the pleural fluid. There is only a minimal pleural effusion now due to pleurodesis in July. Although she did have some increasing side effects from Alimta, these “innumerable lung nodules” had been decreasing in size or stable in scans during the 20 months of first line treatment with Alimta.

My question is - there are a lot of discussions on 2nd, 3rd, 4th etc. line treatment options, but are there any clinical trials or data that would exclude going back to Alimta? Possibly beginning with a carbo doublet and if that slows the progression, then continuing Alimta maintenance?

Reply To: Progression on Gemzar

Hi Fides, So sorry your wife has shown progression on gemzar. There's no significant data to give about moving back to a previous treatments, however, doctors often do move back to drugs that previously showed efficacy, alimta in particular. The exception is platinum, these drugs have been shown to cause hypersensitivity after around 6 cycles, causing more harm than good. After another look it seems your wife hasn't had a platinum?

I'll ask a doctor to comment on your questions.

I hope she is feeling alright and y'all are living life,

Dr Pennell
Reply To: Progression on Gemzar

Hi Fides, I am sorry to hear about your wife's situation. It does sound like the gemcitabine, at least, is not working. It is not clear to me whether your wife was truly progressing on the Alimta, but it sounds like her oncologist felt that she was progressing based on the switch to gemzar. I can't really make any opinions about that based on what you have told me.

Although traditionally oncologists did not "go back" to drugs that have already been used, I would say that attitude is becoming less common with modern agents. I feel very comfortable re-challenging someone with a chemotherapy agent if that drug was stopped for a reason other than progression. For example, if someone has significant fatigue on Alimta after many cycles and wants a break, I would have no problem restarting it again if the cancer progressed many months later. If I was convinced that the cancer had become resistant to that drug, however, it would be rare to try using it again. We will sometimes reuse a chemotherapy drug if it has been a long time since it was used, usually more than a year.

From your signature, I do not see that your wife ever had cisplatin or carboplatin? In situations where a patient has not had platinum chemotherapy, it may be reasonable to consider a platinum combination although there may be reasons her doctor avoided this originally. It would be reasonable to ask her oncologist about this option.

Dr West
Reply To: Progression on Gemzar

I'm also sorry to hear about her recent progression.

I really agree with Dr. Pennell. In the absence of convincing, clinically significant evidence of progression on the agent in question, I am reluctant to discard a treatment too early, at least one of the handful of agents that can be administered for a prolonged period without too many cumulative side effects, and Alimta (pemetrexed) is one of those.

I also agree that a platinum doublet is a tempting idea in someone who hasn't had a platinum before, though the cumulative bone marrow suppression from having been on chemo for years may make it challenging or even infeasible to deliver a doublet years into systemic therapy.

Good luck.

Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

Reply To: Progression on Gemzar

Thank you Janine, Dr. Pennell, and Dr. West for the replies. I believe her Oncologist made the change due to the recurring pleural effusions and the mass in her left lung (primary original tumor) that “most likely” turned out to be scar tissue. Pathology report from VATS came back benign. June 28 CT scan showed stable lung nodules and her last Alimta infusion was 7/1/13. I believe the reason she did not receive a platinum drug in the beginning was that she was diagnosed on 12/20/11, had her 1st chemo next day and her Onc didn’t want to have her sick during the holidays. Then after 3 Alimta infusions the radiology report came back with “dramatic tumor response” in all areas. These responses lasted for 12 months and then stable scans through June 2013. Although blood tumor markers were slowing rising – CEA 7.1 (10/2012) and 33.1 (6/2013). In July/August her Onc did recommend a Carbo/Gemzar doublet but she resisted the Carbo. Her RBC have been averaging around 4.5 so hopefully that will allow the introduction of Carbo and possibly with Alimta.

Thanks again for everyone’s responses.

Steven Weaver