From Tarceva to Geffitinib down the line? - 1254999

apra
Posts:142

Hello everyone,

Our second opinion onc today said that if my husband's scans showed definite progression, then there were several options and he listed them out as Gemcitabne, Navelbine, Docetaxel and even Iressa.

He also recommended Gemcitabine solo instead of carbo combined.

My question is:

1. Is it possible to go on Iressa after progressing on Tarceva? Has this been tried before?

2. After a gap of one year from the last infusion of platinum drugs is it usually safe to go back if the patient has a good performance status?

3. Is a doublet more effective in the third or fourth line instead of a single agent chemo? Presuming that both the chemo and the platinum drug would be given at palliative doses.

4. Do Bisphosphonates alleviate bone pain and also kill some cancer cells in the bones while strengthening the bones?

Sorry for the long list of questions. I hope the answers will be helpful to a lot of other people too.

Thank you.

Apra

Forums
Full Archive

Reply # - March 21, 2013, 01:06 PM

JimC
Posts: 2753

Hi Apra,

As far as your first question, Dr. West has addressed the issue of Iressa after progression on Tarceva:

"I think in the history of lung cancer there may be a single person who has ever been reported to respond to iressa after progressing on Tarceva. There may be two...

"Whatever it is, it's as rare as hens' teeth. I think of Iressa as a slightly less effective version of Tarceva at the standard doses we routinely use (though still may be great for the super-sensitive patients, such as those who have an EGFR mutation, who often have a great response to Iressa with fewer side effects than with Tarceva), so there are a few patients here and there who respond to Tarceva after progressing on Iressa, but I would consider even less likely to see a response to Iressa after Tarceva." - http://cancergrace.org/forums/index.php?topic=2582.msg15354#msg15354

JimC
Forum moderator

Reply # - March 21, 2013, 02:15 PM

JimC
Posts: 2753

Apra,

Moving on to your second and third question, Dr. Weiss has said:

"The decision about whether and when to add back a platinum drug, in both SCLC and NSCLC is controversial. When the 1st line therapy works a long time (and again, we argue about what "long" means, but to give you some idea, 6 months is probably the shortest time that anyone would call "long" and most docs would accept 12 months as "long) this gives reason to believe that the cancer is very sensitive to platinum, and might respond again. However, it's re-introduction is never something standard--it's something "extra" to consider." - http://cancergrace.org/forums/index.php?topic=11095.msg90811#msg90811

And Dr. Weiss added:

"When the depth and duration of response to 1st line carbo/etoposide are deep and long, it is tempting (I believe appropriately so) to re-use platinum if the patient has the functional status for 2 drugs. " - http://cancergrace.org/forums/index.php?topic=11095.msg90968#msg90968

And on the third question, you may want to review this thread: http://cancergrace.org/topic/zometa-and-bone-mets and in particular Dr. Pennell's comments at: http://cancergrace.org/topic/zometa-and-bone-mets#post-1247437

JimC
Forum moderator

Reply # - March 21, 2013, 06:46 PM

Dr West
Posts: 4735

Jim has provided great resources for most of your questions (THANKS, Jim!), and in response to your last, it's possible and has certainly been reported that patients can experience alleviation of pain with bisphosphonates like Zometa (zoledronate), but it's definitely uncommon to rare (perhaps 10%). I personally feel that this is an overestimate and never expect to see it.

These interventions don't really work by killing cancer cells in the bones.

-Dr. West

Reply # - March 21, 2013, 10:00 PM

apra
Posts: 142

Wow Jim, that was thorough! I will go over the threads minutely. THANK YOU !

Dr. West,

Thank you for your response. I asked the question because my husband seems to feel a definite alleviation of pain after Zometa infusions. He was off Zoneta for some months and his bone pain increased. He could not sleep on one side for sometime now. After about four months he d another Zometa infusion on 27th February 2013. Now he is not complaining too much of bone pain and is saying that he can even sleep a bit on the side which he could not sleep on at all.

So I hope Zometa also has some pain alleviating and minute cancer killing property :)

Reply # - March 22, 2013, 07:03 AM

dr. weiss
Posts: 206

I've had a few patients report some relief of bone pain with zometa but I certainly don't rely on it for pain relief. Rather, I use it when appropriate otherwise and am grateful if I also get a little palliative benefit as an extra benefit.

General pain relief measures used for any pain are the most immediate treatment of bone pain--tylenol, NSAIDs, short and long-acting opioids. Radiation can be VERY effective. Chemotherapy, when it works, can be helpful. Finally, when there are no chemo options left but bone pain is a problem, I consider bone-seeking radio-isotopes like samarium that can palliate bone pain. Their problem is that they sometimes hurt the bone marrow to the point that no more chemo is possible, which is why I reserve them for patients who are in comfort-care only mode.

Reply # - March 22, 2013, 07:29 AM

apra
Posts: 142

Dr. Weiss,

Thank you so much. I praise God that we did not opt for Samarium which was offered to us and declined by our 2nd opinion Onc. Taking Samarim meant no Chemo ever again forever? Wow, narrow escape. Yes, Zometa does relieve bone pain.

Jim, your links were priceless. Learned so much. One of hem was my own discussion thread :)

Update on Pet ct scan :

We got the results of my husband's Pet Ct scan as below:

Impression:
1. Metabolically active residual disease involving let LNG upper lobe with mediastinal lymph nodes and multiple sclerotic metastasis.
2. FDG avid small focal enhancing thickening involving right pleura ? Metastatic.

3. Loculated left pleural effusion. Moderate righ pleural effusion and moderate ascites.

4. As compared to previous pet ct dated 23rd November 2012, there is no significant change in skeletal lesions and meiadyinal l,phones. Small pleural deposits are new findings.

The second opinion Onc said there was no reason to change therapy. The first On has not seen this yet as he is away on holiday.

Maybe this is stable disease or what we can't make up our minds. Meanwhile he is weak and keeping all day. Requested Onc to give Denosumab net month as I is now available in India. Wonder whethe it will also have pain relieving properties.

Thanks for listening.

Apra

Reply # - March 22, 2013, 07:53 AM

JimC
Posts: 2753

Hi Apra,

Glad the links helped. As far as whether the scan shows stable disease or progression, there are other factors to consider before changing treatments. Especially if multiple therapies have already been used, it can make sense to accept slow progression on a targeted therapy such as Tarceva, reserving other options for future use. Dr. West wrote about this here: http://cancergrace.org/lung/tag/treatment-beyond-progression/

JimC
Forum moderator

Reply # - March 22, 2013, 09:21 AM

apra
Posts: 142

Thanks Jim,

Perhaps that will be bet. The onc asked him to be off the tablets for a few days to see if ha helps with the stomach issues and sleeping whole dy issues. Hope few days off the Tarceva will not case more havoc he is EGFR negative.

Thanks for the thread. Will read it. We also do not want to jump off this wagon too soon.

Laya, your words have comforted me. Slow progression. Wish the last word could come off the table :)

Reply # - March 23, 2013, 07:01 AM

Dr West
Posts: 4735

I agree that it really sounds like something in the range of stable disease or rather slow, minimal progression. I'd review some of the posts I and perhaps other faculty have done on "stable disease" that have mentioned that even minor progression is not necessarily a reason to change treatments if the current therapy is well tolerated, especially if there isn't a clear great next option to pursue. To me, this sounds very much in the range in which there wouldn't be a good reason to make a change, especially in someone who has been on several prior therapies.

-Dr. West

Reply # - March 23, 2013, 08:02 AM

apra
Posts: 142

Dr. West,

Thanks for your input. The current therapy was very well tolerated for the first few months. His performance status also improved so much. But now fr the last couple of months he is having this stomach issue of bloating and feeling of illness and pain in the outer stomach areas, not stomach pain as such. We thought it could be because of the ascites but the doctors say the ascites is too small to cause problems and cannot even be aspirated. He was losing weight because he could not eat.

He has been off the Tarceva for a day now and his stomach seems to feel a little better. We hope that after a week or so off the Tarceva he will be able to go back on it. Maybe at a lower dose? But he is EGFR negative.

He has never had a treatment break during the whole two years since diagnosis, so maybe this will be a welcome break.

Apra

Reply # - March 23, 2013, 09:35 AM

Dr West
Posts: 4735

It's certainly always reasonable to drop the dose of Tarceva if a person is experiencing significant side effects that make the current dose not sustainable over time.

Good luck.

-Dr. West

Previous PostNext Post