On Wednesday I got my results from first interim CT scan since initial diagnosis in October for SCLC-Ext diagnosis. Despite my feeling very good, doctor told us he was "stumped" as there was effectively zero shrinkage, and some minor progression to the main lymph node tumors after two full cycles of Cisplatin / Etoposide.
I guess the positive news is that CT didn't show any other spread to anywhere else than original spots.
I was sent yesterday for another PET scan to measure any changes in activity levels.PET results showed there has been improvement in SUV's despite lack of tumor shrinkage. Main lymph nodes have gone from 23.3 to 16.1 and spot on liver from 14.2 to 10.3.
I have heard about equal (or in a few cases better) results from replacing Etoposide with Irinotecan. Doc strongly recommends to do one more cycle of Cisplatin / Etoposide and another CT before changing to Irinotecan, but will change right away if I want. He didn't seem to have a clear reason for the preference, other than "that's the way it is normally done in the US".
Could really use some help from the faculty & group in determining (i)are these SUV changes significant or not? and (2) if the tumors are not responding to the Etop, what is the risk in trying this alternative? Could it be worse? (3) Would the third cycle of Cisplatin / Etop cut into the 6 treatment max if we switched after the next round?
Thanks much!!
Reply # - December 21, 2012, 02:33 PM
Reply To: Should I change from Cisplatin / Etoposide to
I'm so sorry you haven't had any better results. There are a couple of things I feel comfortable with answering. The first and most impressive one and why I am here at all is a doctor will let us know if my thinking of wrong.
With sclc you'd really want to see a lot of shrinkage in first line. It's the best indicator of good results moving forward. (but that may not apply to you. Cancer will do what is wants.) A 3rd cycle will not decrease your ability to have more treatment unless it becomes a matter of toxicity. Since you are feeling better that counts for a something. The 6 cycle limit is for the platinum drugs (cisplatin in your case) so you can move forward with other single drug treatments as long as they are thought to be helpful.
I will ask a doctor to comment on your questions. It may take a little time as this is a busy time for everyone responding.
Best of hopes,
Janine
Reply # - December 21, 2012, 02:52 PM
Reply To: Should I change from Cisplatin / Etoposide to
I am sorry to hear that the cancer has not responded well to chemotherapy. About 20-30% of patients with small cell lung cancer will not respond to first-line chemo, although sometimes it remains stable which is still OK. Without seeing the scans myself I can't really say if the cancer is "essentially" stable or is really worse, and I also have to point we can't really give you specific advice on what to do.
However, I can comment on the PET scans. PET scans have not been proven to be useful in restaging for SCLC, so most lung cancer specialists don't use them routinely outside of the initial staging. The SUV value really cannot reliably be compared from one scan to the next, since it depends on lots of variables such as your blood sugar level, the time from injection to scan, and technical variation in the machine itself. I would not trust minor SUV changes from one scan to the next over the changes in size, although major changes such as from "positive" to "negative" can be helpful. The most important factor is the size of the tumors and how you feel clinically. If those are changing they would outweigh anything we see on the PET scan.
Some doctors will change to irinotecan if etoposide isn't working, although there isn't good evidence that is works consistently. I have done it myself, and sometimes have had better results. The side effects are a little different, mainly issues with diarrhea with the irinotecan. There is no hard limit of 6 total cycles, that is just the maximum number most oncologists would give a patient before the side effects tend to start outweighing the benefits, but certainly some people can get more than that if need be.
Whatever you and your doctor decide to do, I wish you the best of luck!
Reply # - December 21, 2012, 03:17 PM
Reply To: Should I change from Cisplatin / Etoposide to
Thanks for your time Dr Pennell, but unfortunately I am not sure I understand what you are saying. Should I interpret the PET scan comments as "the test and results are meaningless"? Also, for the 20 -30% who do not respond to first line, what is normally done?
Understand you can't provide medical advice, but I'm just looking for useful info upon which I can make a decision.
Thanks again
Reply # - December 21, 2012, 03:36 PM
Reply To: Should I change from Cisplatin / Etoposide to
Sorry if I was not clear. In my opinion, PET scans used to judge response in lung cancer are "useless" except for the CT portion which can show you if the cancer is growing, shrinking, or stable. A growing tumor that is lower SUV would generally be considered progression, while a shrinking tumor that is higher SUV I would generally consider responding. Stable disease that has an SUV changing up or down should not be interpreted either way.
For the patients who progress after first line chemo, the standard practice would be to proceed with second line chemotherapy, usually topotecan or irinotecan. However, as I mentioned, when the first couple of cycles of platinum/etoposide fail, it is not unusual to try switching to platinum/irinotecan, although there are no trials proving that helps people live longer. In your case, the interpretation of your scans as to whether the cancer is truly progressing or stable is important, and then you would have to discuss the options with your oncologist to see what seems like the best approach. Sometimes even a second opinion can help when there doesn't seem to be a right answer!
Reply # - December 21, 2012, 03:41 PM
Reply To: Should I change from Cisplatin / Etoposide to
I really agree completely. We generally don't do PET scans for SCLC and rely far more on changes in the size of the measurable disease. I would say that most people who see lesions of the same size with a changing SUV would just consider that stable disease, but it is not typical to do PET scans in routine follow up of SCLC.
And while I agree with Dr. Pennell's outline of options in someone who is having a relatively disappointing response or non-response to first line treatment, there really isn't any standard protocol of how to proceed, and it tends to fall to individual judgment for the situation depending on the patient and the overall pattern of the disease change.
Good luck.
-Dr. West