Our dad has Stage 4 NSCLC, EGFR Mutation, Exon 19 deletion. He has been on TKI therapy with both Tarceva and Tagrisso, but developed pneumonitis on both meds. Despite the pneumonitis, he remained on Tarceva. But after 9 months on Tarceva, there was progression, so our dad started on Tagrisso after confirmation of T790M mutation. He responded well, but pneumonitis recurred 2 months later, this time more severely, leading to hospitalization, high-dose steroids, oxygen supplementation, and withholding of Tagrisso. Repeat CT shows that the pneumonitis is improving, so the question is whether or not to rechallenge with Tagrisso or switch to alternative therapy? Does anyone have experience with this or know of someone who has been successfully rechallenged with Tagrisso? If so, at what dosage and frequency? We appreciate any advice that you can share. Thank you very much.
Tagrisso and pneumonitis - 1288750
slouie
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Posts:2
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Reply # - September 27, 2016, 10:48 AM
Hello,
Hello,
Welcome to GRACE. EGFR-induced pneumonitis can often be a fatal complication, and I think the opinion of most oncologists would be that your dad was lucky to get past it twice. Tha GRACE faculty expressed their views on rechallenging an EGFR TKI in this thread: http://cancergrace.org/forums/index.php?topic=1387.0
JimC
Forum moderator
Reply # - September 27, 2016, 11:23 AM
Hi sl0211,
Hi sl0211,
I'm so sorry your dad is having difficulty tolerating egfr tki. Unfortunately pneumonitis is destructive enough for most oncologists to want to stay away from even when there aren't other options as Dr. West describes in this post,
"As you also know, EGFR-directed therapies are likely to be the overwhelmingly most fruitful approaches, but if she is unable to tolerate Tagrisso (osimertinib) because of pneumonitis, I think there is good reason to be extremely wary about trying it again. " http://cancergrace.org/topic/treatment-options-2
Chemotherapy may still be an option for your dad if he and his oncologist feel he is strong enough to take. Four cycles of a platinum based doublet chemotherapy is usually effective though if he needs or wants something less strenuous a single agent such as alimta may also give excellent results. Usually platinum doublets cause there share of side effects but they can usually be mitigated with counter measures given proactively. Single drugs such as alimta are often very manageable with few or no side effects.
There are options and I hope your dad is able to find one that will keep him stable and living life for a long time to come.
All best,
Janine
Reply # - October 12, 2016, 12:10 PM
Hi Janine and Jim,
Hi Janine and Jim,
Thank you very much for your responses. To give an update, our father's most recent CT showed stable systemic disease and improving pneumonitis, but his brain MRI shows slight progression and possible subtle signs of leptomeningeal carcinomatosis. In light of this new information, do you think that platinum doublet chemotherapy is still the best option in terms of effectiveness and side effect profile?
We are interested in hearing your recommendations, as well as those of Dr. West, Dr. Riely, and other physicians in the forum.
Thank you in advance for your advice. We very much appreciate it.
Reply # - October 13, 2016, 11:21 AM
sI0211,
sI0211,
I'm so sorry to learn of your father's recent results. I hope you can understand that we are not set up to make recommendations for our members. In fact the suggestion of such sways heavily into malpractice territory.
However we do the best we can to give up to date information on standards of care, clinical research, and what is being practiced in clinics by specialists in the field today.
It's important to know that a diagnosis of lepto is often difficult. An MRI can suggest its presence but can also cause a false positive especially if there are no symptoms and only a small suggestion on the MRI. A spinal tape that studies the fluid from the spinal cord is the only way to know for sure but is only about 50% accurate the first time around because of false negative results. I say this because one of the treatments, intracranial chemo is a big decision and many don't go that route because of side effects.
On the other hand, tagrisso is sometimes used for those with egfr t790m mutations. However that appears to not an option for your father because of the dangers pneumonitis pose.
A third option for lepto and for the more typical brain mets is chemo that has shown to penetrate the blood brain barrier. In the case of adeno nsclc alimta is such a drug. So yes chemo is still a good option.
Radiation to the affected areas is another option.
Unfortunately there hasn't been progress in treatment options for lepto. Putting a team together that involves palliative experience is important in cases of lepto and deciding how important it is to confirm. I wish we could help decide on the next steps but this is a very individual process and needs to be addressed by his oncologist and very possibly a 2nd opinion onc who has seen a lot of lepto. This post is several years old but is still relevant. http://cancergrace.org/cancer-treatments/2015/09/23/explaining-leptomen…
Keep asking questions and best to your dad and you.
Janine