semone12
Posts:42
Hello! My mom was recently diagnosed with Stage 4 Adenocarcinoma with lung primary. She had a small tumor on her lower left lung and a couple of lymph nodes. She also had malignant pleural effusion.
To date, she has undergone a VATS procedure followed by pleurodesis and a lung biopsy. She had her first chemo recently with Alimta & Carboplatin. She is tolerating it really well so far.
My question is that should we add Avastin to the above regimen? I understand from my research that Avastin can positively impact PFS and OS. Please guide me as I need to work with her oncologist who is reluctant to ad Avastin. Many thanks, Semone.
Forums
Reply # - April 29, 2014, 12:19 PM
Reply To: Stage 4 Adenocarcinoma – Chemo regimen question
Hi semone12,
Good to hear that so far your mom is tolerating Carbo/Alimta well. In most cases, adding Avastin does not worsen treatment side effects significantly.
The trial evidence in favor of adding Avastin to a two drug platinum combination is mostly from the initial clinical trials with Carbo/Taxol. As Alimta has become a common substitute for Taxol, many oncologists assumed that Avastin would confer a similar benefit when added to Carbo/Alimta.
The issue of whether Avastin is a valuable addition to first line therapy has been discussed here on GRACE previously:
http://cancergrace.org/lung/2009/07/24/patel-regimen-rs/
http://cancergrace.org/lung/2013/06/17/pointbreak-maintenance-therapy-u…
http://cancergrace.org/lung/2013/06/14/pronounce-trial/
JimC
Forum moderator
Reply # - April 29, 2014, 09:49 PM
Reply To: Stage 4 Adenocarcinoma – Chemo regimen question
As Jim indicated, the answer is very equivocal. The fact is that beyond a single trial, Avastin bevacizumab) hasn't been shown to improve survival, and I would say that most lung cancer specialists consider it an option but definitely not a mandate (though there are a few outlier opinions out there that it should be added, it's important to watch that the materials you're reading aren't sponsored by the makers of Avastin). Particularly in patients over 70-75, there is some evidence that the side effects may exceed the beneficial effects of the agent added to chemo. But even in younger patients, the fact that it has never demonstrated a survival benefit in any other trials beyond a single one leads most people to believe that it's a fine option but hardly a wildly compelling core component of treatment. In fact, a trial last year of carbo/Alimta (pemetrexed) without Avastin (bevacizumab) showed survival very similar to an Avastin-containing regimen.
I think it's a strong consideration in younger patients, a pretty dubious one for older patients, and overall it hasn't made a clear case for being a critical component of the regimen. Only a minority of people in the US actually get it (about 25-30% of NSCLC cases), as many have some factor, whether related to age or potential complications from other medical issues, that makes it a questionable choice.
-Dr. West
Reply # - April 29, 2014, 10:59 PM
Reply To: Stage 4 Adenocarcinoma – Chemo regimen question
Dear Jim and Dr. West, thank you for taking the time to reply in such detail. I really appreciate it!
The reasons you shared are probably why my mom's oncologist is not in favor. My mom is 73; however she has been in exceptional health prior to her diagnosis. She is still active and as I said, doing well with the current chemo regimen. However, perhaps there are risks the doctor doesn't think are worth taking.
One additional question, if I may, is that my mom has had a number of tests including PET and CT scans, x-rays, an EGFR test (which came out negative) etc. I think she should have a Brain MRI to hopefully rule out brain mets. However the doctor thinks that CT and PET scan should suffice & don't show any red flags. Please note my mom lives outside the US. Should I insist on a Brain MRI, and why?
Many thanks once again. Regards, Semone
Reply # - April 30, 2014, 05:19 AM
Reply To: Stage 4 Adenocarcinoma – Chemo regimen question
With regard to brain scans at initial diagnosis, Dr. West has said:
"Brain imaging is typically part of the workup for a newly diagnosed lung cancer, since brain metastases are not uncommon and can definitely been seen even in asymptomatic patients. Though we never want to find them, it’s helpful to detect them when small and solitary, rather than because several large ones are present and lead to a seizure as the first sign of brain involvement. It also tends to be helpful to have a good sense of the full extent of disease at baseline, so that if brain metastases become apparent later, you don’t have to guess whether they were there previously or not." - http://cancergrace.org/topic/need-for-base-line-ct-or-mri-of-brain#post…
And Dr. Weiss has said: "I typically acquire an MRI at diagnosis, then again if symptoms suggest." – http://cancergrace.org/lung/topic/should-brain-mri-be-done-even-in-abse…
As far as the difference between CT and MRI for detecting brain lesions, Dr. West has said:
“There is little to no question that head MRIs are superior to CT scans in detecting brain metastases. MRI scans detect a greater number of lesions and defines the location more readily, and they are also better at detecting spread to the meninges, the lining around the brain (and spinal cord).” – http://cancergrace.org/lung/2007/04/05/intro-to-brain-mets/
JimC
Forum moderator
Reply # - April 30, 2014, 06:19 PM
Reply To: Stage 4 Adenocarcinoma – Chemo regimen question
In the US, the current standard is really to do brain imaging as part of initial assessment of advanced lung cancer. PET/CT scans are not really able to provide the detail to rule out brain metastases.
-Dr. West