Good morning all.
Here is my mom's latest update: 65 yrs old. Stage 3A NSCLC Ademonicarcinoma with ten percent of her cells possibly testing positive for squamous. 6cm central, upper left lobe tumor that is beginning to invade pulmonary artery. Tested negative for all mutations.
At first, we were told she needed neoadjuvant therapy. Then, told by oncologist to go straight to surgery. Finally, informed that the decision to move on to surgery was not supported by surgeon. Surgeon explained on Friday that my mom definitely requires neoadjuvant therapy prior to any possibility of surgery, which would likely be a Pneumonectomy or sleeve resection (if at all).
So, here is my dilemma again.
Option 1: The team recommends the clinical trial of Nivolumab (Opdivo) for two infusions only (that's the way the trial is written.). If it works, surgery. If not, move on to chemo and/or possibly rads. I'm not quite sure what two infusions only is supposed to accomplish. We were told that it may be able to help body later on if cancer returns.
Option 2: Standard chemotherapy with the possibility of adding radiaton. We were given a choice of cisplatin and docetaxel OR carboplatin and docetaxel. Oncologist said cisplatin tends to "work" better. Does anyone have insight on choice of chemotherapy cocktail?
Thank you to all and Happy Morhers Day to those celebrating.
Reply # - May 8, 2016, 11:50 AM
Hi greekgirl,
Hi greekgirl,
I'm not sure what the thinking is on the Nivolumab option, as immunotherapies can take several weeks to show effects, so I can't see that it would make the surgery any easier unless you wait a bit to judge efficacy. It is possible for just a couple infusions of Nivolumab to be effective though, so it could help.
As far as the chemo choices, cisplatin is touted as the more effective choice, but it can be more difficult to tolerate, especially when combined with another drug that can be tough, docetaxel (Taxotere). There's a good discussion of the pros and cons (albeit in the adjuvant setting, although the same considerations tend to apply) in this thread. It's a few years old, but the same considerations apply today.
The latest GRACE podcast on neoadjuvant (pre-operative) chemo can be found here.
JimC
Forum moderator
Reply # - May 8, 2016, 01:51 PM
I"m not sure I understand the
I"m not sure I understand the use of radiation if they're going to do surgery also. Any comment Jim?
Take care, Judy
Reply # - May 8, 2016, 02:01 PM
Hi Judy!
Hi Judy!
I agree. I didn't think to ask that question at MSKCC while I was there because I didn't know that radiation causes so much scar tissue until I googled it last night. Thoughts?
I showed two surgeons the images. Both said that they won't know for sure what exactly is resectable until they actually begin to operate. Both said it looks like a potential Pneumonectomy if it can be resected. No guarantees. Pulmonary artery invasion makes it dangerous.
Oncologist told us we can do cisplatin for one infusion and if my mom can't tolerate, she can switch to carbo. Thoughts on that, too?
Jim, I read that thread. Boy, oh boy, great information. My goal is to get to surgery if possible. Maybe carbo will have less side effects and don't delay surgery potentially?
Reply # - May 8, 2016, 05:39 PM
When I read the options, I
When I read the options, I thought that the use of chemo/radiation was to be in place of surgery. In other words (as you state in option 1), if either Nivolumab or chemotherapy is successful, then surgery, and if not, then chemorads. That would be a pretty typical approach to treatment of Stage IIIa - surgery if possible, otherwise chemo/radiation.
As far as the danger of surgery, this is one of the situations (as is often the case with arguably resectable stage IIIa lung cancer) which demands the participation of an experienced thoracic surgeon who specializes in this type of surgery, as opposed to a surgeon who does this surgery and many other types. I'm sure MSKCC has a surgeon that meets these criteria.
It's not unusual to begin a chemo regimen and adjust dosages and/or switch from cisplatin to carboplatin if side effects are too difficult. As Dr. West has said:
"In terms of the activity of these agents post-operatively, the evidence is stronger with cisplatin, which is why experts typically favor cisplatin in patients who can tolerate it. There are not nearly as many studies with carboplatin, and the data in other settings suggests that carboplatin may be a shade less active. While we'd want to give the most effective treatment, it's only going to be valuable therapy if a patient can successfully get it without prohibitive side effects. I would not hesitate to recommend carboplatin-based chemo in someone in whom I thought that cisplatin-based chemo was not likely to be feasible, and I have many patients who have done extremely well after either switching from cisplatin to carboplatin due to side effects, or starting with carboplatin from the beginning for one reason or another." - http://cancergrace.org/forums/index.php?topic=4388.msg26172#msg26172 (Please note that the comment by Dr. Sanborn regarding pairing platinum with Alimta has likely not been recommended to you because Alimta isn't a good choice for squamous).
JimC
Forum moderator
Reply # - May 8, 2016, 06:12 PM
Hi Jim.
Hi Jim.
I'm so Sorry I confused you. Both options are meant to be admistered prior to surgery. To clarify, option 2 choices would be before surgery. So, the addition of radiation would be prior to the surgery. Is that feasible?
So, the oncologist proposed Nivolumab. If that doesn't work, go to chemo. Possibly add radiation. And finally, hopefully, get to surgery. All those therapies are meant to be administered before surgery. They left the choice to my family. We were very confused as to which therapy route to use prior to surgery. Thoughts on safest way to get to surgery for the patient?
As for the potential resectability, the surgeon at MSKCC is highly regarded. So, if my mom ever becomes Resectable, I do have confidence in the surgeon.
Thank you.
Reply # - May 9, 2016, 07:58 AM
Hi greekgirl,
Hi greekgirl,
No need to apologize, that's just the way I chose to read what you had written. Dr. Socinski has compared the use of chemotherapy vs. chemo/radiation in the neoadjuvant setting in this podcast. As he states, the data isn't completely clear as to which is better, but there are additional risks of complications from adding radiation. Those risks can best be judged by the local medical team, and as Dr. Socinski states, it's good that an experienced surgeon is on board from the beginning.
JimC
Forum moderator
Reply # - May 10, 2016, 10:45 AM
Hi Jim!
Hi Jim!
I really appreciate that information. Helps make the decision for treatment much more educated and informed.
Question, for the clinical trial of nivolumab (Opdivo) of two infusions prior to surgery, what would the goal of that study be? Is it to shrink tumor? Is it to rev up immune system? I'm trying to decide how this treatment of 2 infusions would be useful or beneficial to my mother (over chemo) at the preoperative Stage 3A.
Also, do resectable candidates whom receive standard chemotherapy often find a delay in their surgery because the body is too weak?
Thanks a million!
Reply # - May 10, 2016, 03:22 PM
The website clinicaltrials
The website clinicaltrials.gov has info about most trials happening in the world. The following is from that site and describes the trials purpose,
"Purpose
Anti-PD-1 (nivolumab) administration in the pre-operative setting will be safe and feasible in patients with resectable NSCLC.
Anti-PD-1 (nivolumab) administration will change cellular and molecular characteristics of the tumor microenvironment that can be quantitatively measured.
Failure to respond to anti-PD-1 in NSCLC results from either pre-existing or compensatory (i.e. adaptive) up-regulation of additional immune "checkpoint" pathways in the tumor, draining lymph nodes, and/or peripheral blood that inhibit immune recognition and killing of tumor cells. Characterization of these pathways (i.e. ligands and receptors) in patients receiving preoperative anti-PD-1, and comparison with a cohort of patients who proceed to surgical resection without preoperative anti-PD-1, will illuminate mechanisms of adaptation and immune resistance to directly guide future therapeutic development of anti-PD-1 as monotherapy and in combination with other immunomodulators in NSCLC." https://clinicaltrials.gov/ct2/show/NCT02259621?term=nivolumab+%28Opdiv…
Chemo and radiation can be grueling for many especially when followed by surgery. It's something that an oncologist and team can best make. These are huge decisions for a family to make. I've heard loved ones, patients and doctors all speak about the "what would you do if it were your mom" question. Maybe worthwhile wording to get a more personal thought process from her onc.
All best,
Janine