Should he "go" for Chemotherapy or not - 1251046

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Should he "go" for Chemotherapy or not - 1251046

My 75 year old father was diagnosed this week with a Stage 4 large cell neuroendocrine tumour.

He’d gone to the GP several months ago complaining of breathlessness and back pain, he’d been several times previously and essentially nothing had been done, but on this occasion the GP referred him for a CT scan. Based on the scan, which was some 6 months ago, doctors diagnosed that he had osteoporosis, but they failed to “see” the tumour.

Being a rather “failing” 75 year old (rather than some of the remarkably fit and healthy 75 year olds that you see getting on with their lifes) he and my mother regularly visit their GP and on each occasion since the scan he complained of occasional chest pains, general fatigue and breathlessness. On one visit, some 3 months ago, the GP reffered him for an X-ray – this time they “saw” a shadow on his right lung and arranged for him to be seen by a consultant.

The consultant confirmed that the tumour was evident on the original CT scan and had been missed by his colleagues! He also advised that they couldn’t undertake a CT-guided biopsy because of fluid around the lung – some of this was fluid was drained and sent for analysis. The fluid proved inconclusive so he then had some form of biopsy (I’m afraid that I didn’t note the medical term for the procedure). The results being that it was the Stage 4 large cell neuroendocrine tumour lung cancer I refer to above.

The doctor had hoped to drain more of the fluid to ease the breathing, but the x-rays showed that the amount of fluid hadn’t really increased in the last month, so it was not worth it. What’s causing the ever-increasing breathlessness is the increasing size/affect tumour, and not the fluid. Understandably he refused to answer Dad’s inevitable question – how long have I got!

So, the question. Given he’s a rather “old” 75, and the incurable nature of the cancer, do I advise him to take the Chemo and all it’s “risks” or not? He has very little pain in the chest area.

certain spring
Reply To: Should he "go" for Chemotherapy or not

Just H, I'm so sorry to hear about your father. What a blow, and how frustrating that the tumour was missed. I hope you have made your feelings plain.
The GRACE doctors have written quite a lot about chemotherapy in the elderly - essentially dividing older people into the ''fit elderly', who may benefit from chemotherapy, and the 'frail elderly' who are more likely to experience kidney problems and so on. They won't be able to advise you what to do, but can give you a general sense of how they would approach the problem.
What about your father, does he have a view on this? Has he been offered any other kind of treatment, such as radiotherapy? Actually I think the consultant should have tried to answer your father's question, since he was asked directly.
Here is a post that takes the reader through the issues facing elderly patients with lung cancer:
I'm sure you'll hear from a doctor later. Best wishes.

Reply To: Should he "go" for Chemotherapy or not

H, I'm so sorry your father is so sick. Most people are like me coming into this situation without any real knowledge of cancer care in today's world. My father died of cancer in 1970 when I was 11 and I've lived happily without needing any real understanding of how treatment works. Well that changes for those who come through Grace. We get and give knowledge to others so they can make or help make treatment decisions.

The first thing you should know is that stage 4 lung cancer can be very treatable and give the person good quality life for years. You are right to worry about your father's other issues called co-morbidities that can make some treatments not worth the toxicity. The trick is to find a balance that gives your dad stable or better quality of life and adding quantity in the process. The most difficult and worrisome for me and many others is judging when focusing on comfort/quality only is the thing to do.

Radiation for a person with stage 4 is usually saved for when the tumor obstructs a structure like the windpipe as it sounds like is your father's main issue. Has his doctor mentioned being able to do that?

Let me link you to some blog/post written by our faculty to give you an understanding where your dad stands.
Start here, this is a new 5 ish minute video where Dr. West describes systemic treatment (IV or pill treatments that focus on the whole body) and occasions where you would use radiation in stage 4 and when not (I think this may apply to your dad).

And here is a piece geared toward those who are elderly or in poor physical condition.
And lastly, for now, is the list of pieces written on elderly and frail population,

I hope this is helpful,
forum moderator

Dr West
Reply To: Should he "go" for Chemotherapy or not

I'm also sad to hear of your father's diagnosis and poor health. Adding to the good information already provided by certain spring and Janine, I would say that the studies show that chemotherapy can improve survival by an average of a few months in patients who are up and around at least half the day. If more debilitated than that, there's a very real risk that the treatment could be worse than the disease, or at least provide no benefit and only side effects. This judgment of performance status (functional ability) is somewhat subjective and is not really feasible to assess over the internet.

In addition to the issue of his likely marginal performance status, large cell neuroendocrine carcinoma of the lung is recognized by most oncologists, including lung cancer specialists, as a subtype that is difficult to treat and tends to not respond as well as some others. This isn't an absolute, and there are definitely exceptions, but it may be a factor worth considering along with the other variables.

In the end, it comes down to a combination of the judgment of the doctor(s) involved and the preferences of the patient and caregivers/family. Some people may want to do everything feasible, even knowing that it could be harmful, but they want to "go down fighting". Others may feel that the benefit of a few months doesn't sound impressive enough to bother with chemotherapy. There are situations in which we feel that the value of treatment is so great that we'd want to nudge a patient to try it even if they're hesitant. Unfortunately, this isn't one of those situations, so even if I think it's a reasonable option to pursue treatment, I don't think that he'd be missing out on any great opportunities if he doesn't.

Also, remember that focusing on his comfort isn't the same as doing nothing.

Good luck with whatever he/you decide to do or not do.

-Dr. West

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

Founder & President
Global Resource for Advancing
Cancer Education

laya d.
Reply To: Should he "go" for Chemotherapy or not

I just wanted to add that I am so sorry to read of your Dad's diagnosis. . .and wish him all the best.

Please keep us posted on how he is doing. . .


Reply To: Should he "go" for Chemotherapy or not

Thank you all for your comments, be they supportive and/or informative, they really do help a lot. It's so good to know that people are "there" not only for the patient, but also for family and friends. I suppose it's dealt with differently by everyone.

He's having a pre-treatment consultation and a nuclear bone-scan this week, so although he's not yet decided on whether to have chemo or not, I'm sure that the additional information we'll hopefully have at the end of it, will all help to make that difficult decision.

I will do all I can to keep this thread updated. Again, thank you all very much.