Husband has NSCLC Stage IV, plus bones, brain, adrenal gland and lymph node. Diagnosed Dec 23, 2013 He's been on tarceva since Jan 24 2014, One round of chemo while waiting on EGFR results. After 30 days at 150, husband dropped to Tarceva 100 due to side effects. April -14 scan showed marked improvement and no areas of activity. Aug-14 scan showed slight improvements in most areas but new growth/activity in hip, shoulder, spine (some activity in prior sites and some new sites). Dr said some may be related to bones healing from radiation (jan) Not sure if it could be related but we recently switched from zometa to xgeva (due to side effects) .
Dr suggesting we increase tarceva back to 150 as one option. Add cetuximab was another option. I've seen on this site that Tarceva plus cetuximab showed no improvement but cetuximab with afatinib are showing good results. i worry that if Tarceva is working on the original turmors, if switching o afatinib puts my husband at risk. I've also seen Tarceva plus Avasin seems to be a good combination but Im not clear when any one of these would be the most appropriate. I did talk to dr about re biopsy but growth is in the bone and she said would be difficult and likely inconclusive. I'm also worried around new brain mets, his MRI is in another week.
Any information on the various options above and when you might use one vs another would be greatly appreciated. Thank you
Reply # - September 7, 2014, 06:55 PM
Hi angieb,
Hi angieb,
Welcome to GRACE. I'm sorry to hear of your husband's bone mets, although otherwise his response to Tarceva has been great.
I too would be somewhat concerned about switching away from Tarceva when it seems to have kept the rest of his disease under control. And I don't think that anyone can say whether Tarceva/Avastin would be better than cetuximab plus afatinib - there just isn't enough evidence to make a definitive statement.
One consideration is that the skin side effects of the afatinib/cetuximab combination can be quite challenging, and if your husband had trouble with the full standard dosage of Tarceva, that regimen might be intolerable. It's impossible to say whether a higher dosage of Tarceva will help, but since he had a very good response to 100 mg; raising the dose to 150 mg may just add toxicity with improving efficacy, as some patients who are particularly sensitive to the drug do very well at dosages as low as 25 mg.
In addition to the options you listed, some oncologists recommend continuing Tarceva while adding a standard chemo agent such Alimta, on the theory that there are cancer cells which are not sensitive to Tarceva but which will respond to chemotherapy.
The question of what to do after a patient has developed acquired resistance to EGFR TKIs such as Tarceva is one which has sparked much debate in the oncology community. If you search this site for the term "acquired resistance" you will find a great deal of information and varied perspectives.
Please let us know if you have more questions, and good luck with the MRI.
JimC
Forum moderator
Reply # - September 7, 2014, 10:00 PM
Just yesterday we had a
Just yesterday we had a conference lasting about 7 hours that discussed various options, so there isn't one best answer. One point that was raised is that none of the experts agreed on is that raising the dose after having reduced it earlier is an approach that none of us is at all enthusiastic about. It's true that afatinib and cetuximab has looked favorable in a trial with small numbers that we'd like to validate with a larger trial. Other agents that have looked very promising include CO-1686 and AZD9291, which are specifically being studied in patients with a T790M mutation, seen in about 60% of people with acquired resistance after a very good initial response. That can only be determined by a repeat biopsy. In contrast with what your oncologist said, a growing proportion of experts are favoring a repeat biopsy IF you could get access to one of these agents like CO-1686 or AZD9291 in a clinical trial (most likely to be available at a larger cancer center, especially an academic center).
You can learn more about the options from searching for "acquired resistance" and reviewing the many issues discussed.
Good luck.
-Dr. West
Reply # - September 22, 2014, 02:26 PM
Thank you both for your reply
Thank you both for your reply. Dr. West. We have scheduled an appointment to come to Seattle next week. Unfortunately my husband is now every other day on the 150/100 Tarceva until we understand our other options. It is so toxic for him. It makes him question if it is worth it. On a positive note - His brain scan came back clear.
Unfortunately our oncologist said a biopsy of the progression would be difficult because it is in the bones and still very small. We would be interested in getting your thoughts. I did listen via the live feed on the acquired resistance forum. I understand it is difficult but with the right technology it is possible, correct? Unfortunately the second half for EGFR was not broadcast so I'm waiting for the presentations to be go on the site
Reply # - September 22, 2014, 03:07 PM
Hi Angie,
Hi Angie,
Great news on the brain MRI!
Yes, a bone biopsy can be difficult because it is not easy to get tissue with active cancer cells, especially if the lesions are small and the lesions have been previously treated. As Dr. West has written:
"I do agree that it’s possible to do mutation testing from bone lesions, but they are less reliable in obtaining results than from some other sources. I believe much depends on the chemicals and duration of decalcification of the bone biopsy before tissue goes for testing.
In terms of getting piece of bone from a CT-guided biopsy vs. an open biopsy, it’s certainly possible to try to do the imaging-guided procedure, though it’s probably less reliable than an open biopsy, since the needle needs to go into the lesion, and it’s hard to know EXACTLY where there is viable cancer vs. an inflammatory or healing response to the metastasis. Having a bigger, open biopsy simply increases the odds of collecting tissue with active cancer." - http://cancergrace.org/topic/biopsy-from-bone-mets#post-1247568
JimC
Forum moderator
Reply # - September 22, 2014, 05:06 PM
jim
jim
thanks so much for your quick response. This site is so amazing. Your responsiveness and insight are greatly appreciated.