question about Tarceva - 1249979

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likun166
question about Tarceva - 1249979

Hi there,

How are you? I have a quick question about Tarceva usage. My dad was diagnosed with Stage IV NSCLC about two years ago. He has tumor on the left lung and spread to the bones of the full upper body and part of the lower body. He was put on Tarceva since this summer. And it worked really well on him. The blood count of cancerous cells and the size of the tumor have decreased dramatically. My mom has concerns about continuous use of Tarceva. When can my dad stop using Tarceva? I've heard that if on Tarceva the patient has to use it for the rest of the life unless it stops working. Is that true? If not, can he stop using Tarceva if the cancer is totally under control? Any help will be deeply appreciated from my whole family.

Thanks,
lifeng

cards7up
Reply To: question about Tarceva

I think you've answered your own question. Since your father is stage IV, he will continue on Tarceva until it stops working, which would mean progression. The Tarceva is keeping the cancer at bay otherwise he'd probably have progression. What is your mother's concern? I am not a doctor or one of the moderators. I lost my mom to SCLC and I have NSCLC. Wishing your Dad the best. Take care, Judy

catdander
Reply To: question about Tarceva

Hello lifeng, Welcome to Grace. I'm sorry your dad is in this position.

He is stage 4 which means the cancer isn't curable but is treatable as long as treatment works. But that means he will need to be on treatment most of the time. Judy is right tarceva will be continued until it is no longer controlling his cancer or it becomes too difficult/too toxic for your father to take. For the most part people are able to continue tarceva until the cancer builds a resistance to it. Unfortunately your dad will more than likely soon experience cancer progression after a break in treatment. Still it is very reasonable to take a break and watch closely if your dad is experiencing side effects.

What is your mom's concerns? There are many ways to control side effects.

When we hear back from you about the specifics of your mom's concerns we will contact a doctor to give better feedback to your questions.

I look forward to hearing back,
Janine
forum moderator

FYI, you only need to ask your questions in one area. We see them all in one spot so I erased the other one.

Dr West
Reply To: question about Tarceva

Yes, as Judy and Janine indicated, the general approach is to continue the Tarceva (erlotinib) as long as it remains tolerated and is working. In patients who have a good response, we typically see pretty quick progression if they stop it for more than a few weeks. The great control with Tarceva really requires ongoing treatment.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

likun166
Reply To: question about Tarceva

Hi Judy, Janine, and Dr. West,

Thank you all for your precious comments and advices on my question. As you suggested, I'll let my dad continuously use Tarceva. Hopefully it will work on him for a long time. My mom's concern is that my dad needs to deal with rashes and on-and-off fever when taking Tarceva. Plus, no insurance covers Tarceva usage in China. But after ensuring that my dad needs to continue using Tarceva, either of these concerns will be the problem. By the way, recently I've heard that Xgeva (monthly injection) can help bone metastasis from NSCLC. Is that true? And how effective will it be? Should I let my dad try that when taking Tarceva at the same time? Anyway, thank again, you all. You have a wonderful weekend.

best,
lifeng

catdander
Reply To: question about Tarceva

There are many discussions here that cover others' handling of the tarceva rash. You can do a search or go to the EGFR section of the site for that info. The main thing is to keep the skin moisturized.

Xgava is a drug that has been shown to lessen adverse affects of bone mets of existing mets. Again there is much written On the subject on the site. Try the Focused Info links at the top of the page to access doctor blogs on the subject. But yes it can be used with tarceva.

I will contact a doctor to provide more input on your questions.

Janine
Forum moderator.

certain spring
Reply To: question about Tarceva

Hi likun166. You mentioned that your mother was worried about your dad's "rashes and on-and-off fever when taking Tarceva".
I don't think the fevers would be anything to do with the Tarceva. They might be the result of chest infections, which are common in lung cancer. Or sometimes the tumour itself can cause low-grade fevers. But having a raised temperature is not a side-effect of the drug as far as I know.
On the rash and skin problems, there are some useful posts on GRACE by a world expert, Dr Lacouture, a New York dermatologist who has posted on GRACE, for example this one:
http://cancergrace.org/cancer-treatments/files/2011/09/qa-dr-lacouture-o...
Best wishes to your family, and hope the Tarceva continues to work well for your father.

Dr West
Reply To: question about Tarceva

Janine and certain spring provided key information, but here are a few links on XGEVA (denosumab) and the benefits it confers:

http://cancergrace.org/cancer-treatments/2010/11/29/xgeva-denosumab-for-...

http://cancergrace.org/lung/2011/07/15/xgevavszometascagliottiwclc/

It is routinely given in conjunction with chemotherapy or a targeted therapy like Tarceva (erlotinib),

Good luck.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

Dr Sanborn
Reply To: question about Tarceva

Hello--

I have had other patients ask if they can stop taking Tarceva once it is working. However, when a person has stage IV lung cancer, it is important to remember that even if the cancer sites shrink, and even if they no longer are visible, the Tarceva has not killed all of the cancer off. Tarceva can help to shrink or more commonly slow down lung cancer, but there are still cancer cells underneath waiting for the Tarceva "brakes" to be taken off so they can grow again.
The important thing is to keep the symptoms managed as best as possible to keep a person's quality of life good. As mentioned above there are lots of helpful posts on this site discussing this.
In regards to the fevers, it would be very unusual for Tarceva to cause fevers, although not impossible. Any drug can cause a fever in an individual person, but one would want to make sure that the fevers weren''t coming from somewhere else (like infection) before assuming it's the Tarceva.

We do have patients who take both Tarceva and Xgeva (or Zometa) when there are sites in the bone involved.

Take care

likun166
Reply To: question about Tarceva

Thanks, you all, for your helpful responses. Now I understand that my dad needs to keep taking Tarceva. But another question I have is whether he can take lower dose like 100mg tablet or 25mg tablet (now he is on 150mg tablet) if he becomes no evidence of cancer or much smaller tumor. Thanks again.

catdander
Reply To: question about Tarceva

Many people including my husband have benefited from a lowered dose of tarceva. Some as low as 25mg. There is a lot of info written on the subject. I hope this helps.

Janine

Here is a blog post by Dr West on the subject, http://cancergrace.org/lung/2010/05/24/dose-vs-efficacyof-egfr-tki/

and this is the plethora of threads of the subject (you may need to log off to access this one, depending on browser), http://cancergrace.org/search-results?q=tarceva%20reduced%20dose

sherrys
Reply To: question about Tarceva

I hate to jump in on someone else's question, but I saw this statement and it led me to a question.

Dr. West stated, "In patients who have a good response, we typically see pretty quick progression if they stop it for more than a few weeks."

I started Tarceva at 150 mg in September, but due to the side effects, I haven't been on it for more than 3 weeks at a time. My oncologist was at first reducing the dosage, and now he started me on 25 mg for 2 weeks, and now 50 mg for 2 weeks. The hope is to increase until I reach 100 mg. I have not had any scans because I haven't been on it long enough continuously. Does this mean that I should be concerned that the cancer has progressed during the times I have not been on Tarceva?

catdander
Reply To: question about Tarceva

Sherry don't worry about the question I think it only makes the conversation more meaningful.

I think Dr. West is talking about people who have been on tarceva a while, like a year or more, who have shown significant shrinkage, then stop. It only happens to some of the people with the mutation and at least for now there's no way to know who that will be. It's my understanding you don't fit that description.
I hope you get the dosage that you can live with.

Dr West
Reply To: question about Tarceva

Right. First,I think I overstated it by saying that we typically see anything...it varies a lot from person to person. Second, I'm talking about people in whom we've seen a major response over a prolonged period, then suddenly remove that suppressive effect.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

certain spring
Reply To: question about Tarceva

Er, yes, I am afraid I too have a question on this, though different from Sherry's. In the context of the sub-group of long-term responders you just described, Dr West, is there anything that can help to identify or predict which patients are most likely to experience 'rebound progression'? Many thanks.

Dr West
Reply To: question about Tarceva

This isn't hard science, but I'd say it's the situation in which someone has what is technically progression, but they still have less of a disease burden than they started with before the EGFR inhibitor, and they have a relatively slow even if convincing rate of progression. Essentially, think of it like bad brakes: if you're just slipping a bit, taking your foot off the brake will make things speed up greatly (the brakes are still definitely doing something). On the other hand, if you've got your foot on the brake and things are just speeding along as if you're doing nothing, removing your foot from the brake (stopping the EGFR inhibitor) isn't likely to make any difference (i.e., not likely to see rebound progression).

Apologies for the simple explanation here, but I think it actually works (and it's accessible to anyone).

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

certain spring
Reply To: question about Tarceva

I'm grateful for the answer, thank you Dr West.
But I think the question you're answering is - "In what kind of scenario might we continue with the EGFR inhibitor?" Whereas I'm asking, "Are there any clinical predictors for knowing which long-term responders will experience rebound progression if you take them off the TKI inhibitor?" Or just "How common is it for long-term responders to experience rebound progression?"

likun166
Reply To: question about Tarceva

Hi all,

I love all the discussions you have about the question I brought. But I still didn't get answers to my question. Dr. West, do you think my dad should continue with 150mg Tarceva even though he will turn to no evidence in the future or the tumor shrinks to a very small one. Thanks.

catdander
Reply To: question about Tarceva

likun, I'm sorry but I think we answered as well as we can. No one can tell you what your dad should do. That's a decision that must be made by your dad and his doctors.

Again, here are the posts that cover the issue of decreasing the dosage,
Here is a blog post by Dr West on the subject, http://cancergrace.org/lung/2010/05/24/dose-vs-efficacyof-egfr-tki/
and this is the plethora of threads of the subject (you may need to log off to access this one, depending on browser), http://cancergrace.org/search-results?q=tarceva%20reduced%20dose

I know how difficult it is to want an answer to a question about how to treat this awful disease, but all too often it depends.

The questions being asked by Sherry and certain spring are very much related to your questions. Read what has been suggested and what has been asked and written because it adds to what you want to know. After that if you still don't understand please ask another specific question.

Lots of luck,
Janine

Dr West
Reply To: question about Tarceva

Right. We can't answer "should" questions -- except to say that you should speak with the actual doctors directly involved.

CS -- there's really too little information to give reliable numbers, but my answer is really directly related to the question you asked...those patients who still have less disease burden than they did pre-EGFR inhibitor, and who are showing only slight gradual progression are the ones who are most likely to show rebound progression. The only number assigned was that 20-25% in a small series from Memorial Sloan-Kettering had progression that required hospitalization within two weeks of stopping the EGFR tyrosine kinase inhibitor. However, I have almost never had a patient experience that degree of rebound progression and would consider the probability to be under 10%, and perhaps below 5%.

-Dr. West

+++++++++++++++++++++++++
Dr. Howard (Jack) West
Medical Oncologist
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

certain spring
Reply To: question about Tarceva

Thanks Dr West, I was struggling with the brakes analogy but I think I've got it now! Interesting that you've not often encountered it yourself.
likun166, I'm sorry to have crashed your thread and I hope your father continues to do well for a long time.