Tarceva Resitance - 1267901

Rene,

I'm sorry to hear this, but it's exactly what you'd expect to see from early resistance. While these could be benign, I'd be lying if I said that's remotely likely. Even so, this doesn't mean it's necessary to panic or make any changes. These are still very small and asymptomatic. When progression becomes clinically significant enough to warrant a change in treatment is COMPLETELY subjective, and I don't think it would be a mistake to look into changes sometime soon, but I would urge you to not feel remotely rushed about the process. Nothing is happening quickly, and I think it is extremely unlikely that things would turn out any different if you made a change now or 3 months or 6 months from now.

Practically speaking, a leading option in someone developing acquired resistance would be to repeat a biopsy of a progressing lesion and look for the T790M mutation. If it is present, either of the third generation EGFR TKIs in wide testing, AZD9291 or rociletinib (CO-1686), have very promising activity and are being tested in several very large trials. However, it would be exceptionally difficult to try to biopsy a 3 mm nodule. One very reasonable approach would be to wait until there is an area of progression big enough to biopsy before pursuing a change.

Finally, chemotherapy remains a reasonable option after progression on an EGFR TKI. After years of only being able to speculate about whether we should continue the EGFR TKI after starting chemotherapy, the IMPRESS trial recently demonstrated no improvement in progression-free survival and a strong trend toward worse overall survival in the patients who continued EGFR TKI with concurrent chemotherapy compared with the patients who stopped EGFR TKI and went on to chemo alone. So most experts would now favor discontinuing the EGFR TKI when a decision is made to start chemotherapy.

Good luck.

-Dr. West

Hi Rene,

There has been some controversy about the relative effectiveness of chemotherapy in BAC, but recent evidence (and Dr. West's experience) suggests that it is effective: http://cancergrace.org/lung/2006/11/05/chemotherapy-in-advanced-bronchi…

JimC
Forum moderator

I wouldn't want to be too heavy handed about this, but the dismissive view that chemo is ineffective is not based on evidence. The activity of chemotherapy for BAC is hard to assess because the disease is not as easy to measure on scans as more solid, discrete lung cancers, but the limited evidence we have is that chemotherapy is comparably effective for BAC as it is for other forms of adenocarcinoma.

Depending on the surgeon you ask, surgery is always an option for relapsed BAC or almost anything. You can usually find an obliging surgeon if you look hard enough. But is it helpful? I would say that with rare exceptions, the answer is no, and it most often just leads to people having lung tissue removed, then having new BAC lesions appear that have less available good lung to help compensate for the cancer-affected lung tissue.

Good luck.

-Dr. West