To wait another two weeks or to start the therapy? - 1251392

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To wait another two weeks or to start the therapy? - 1251392

Dear all,

if you remember (I've posted recently), my mom has received Ramucirumab or Placebo and a bit of Taxotere 10 days ago (Friday, 03.12.2012), I say "a bit", since she had an acute allergic reaction, so the infusion was stopped.

Last week we were waiting to hear about the half-life of Ramucirumab from the clinical trial sponsor, since the doctor was concerned to give my mom Alimta just like that. When yesterday they still did not call us, I phoned the doctor to ask. He again contacted the sponsor and received the answer that the was three weeks and that we would need to wait another two weeks to start with Alimta!

Now, this has made me really upset and nervous. First, we do not know if my mom received Ramucirumab at all! The sponsor does not want to reveal it, since it would mess up their statistics (stats are more important then patients). Second, my mom has been diagnosed with these new mets to the liver ONE MONTH AGO already - and for one month she has been without therapy! If the mets were say 0.5cm, I would say perhaps - ok, what's another week or two. But they were 1.8cm! And God knows how big they are now. And I feel like we've been waiting too long anyhow. So I said that I do not understand what the concerns were. That Taxotere is anyhow given to Ramucirumab, and that my humble assumption is that they chose Taxotere since it's cheaper then Alimta. In addition, Alimta is given together with Avastin, which works in a similar (I know - not exact the same) way like Ramucirumab. But overall - her values are stable, blood is ok, blood pressure too - I don't want to wait another two weeks - and this perhaps in vain! Because, she might have as well received only a Placebo.

So the doctor said that for his own conscious he would wait these two weeks, but if we want to start next week, we can. And we said we want to - next Wednesday.

Was this a reasonable decision?!

Thanks a lot in advance!!!

Dr West
Reply To: To wait another two weeks or to start the therapy?

Of course, we can't tell a person what they should do, but I agree that the concern about a harmful interaction is likely overblown. First, as you say, we routinely give the combination of Alimta (pemetrexed) with Avastin (bevacizumab) in certain patients, very deliberately, and there is extremely little concern of any particularly harmful interaction. I would consider there to be a similarly small, even if still not completely defined, risk of Alimta with ramicirumab.

Oncology and really all of medicine (even life, perhaps) is full of decisions about anticipated benefit vs. risk of one approach over another. As you say, there are risks of treating, but they are more theoretical than real, and it's not as if the two week wait is a magic number that is established based on any remote's just completely made up and speculative. I would add that there is nothing about the size of the liver lesions that screams of urgency either, but I can certainly see your point that the perceived risks of treating are likely overstated and therefore not worth waiting longer.

In the end, it's all a judgment, with no right or wrong answer, but I share your perspective that the level of concern about side effects in this case seems extremely conservative, and risks of avoiding treatment-related side effects may be more than offset by the risks of also not benefiting from treatment.

-Dr. West

Dr. Howard (Jack) West
Associate Clinical Professor
Medical Oncology
City of Hope Cancer Center
Duarte, CA

Founder & President
Global Resource for Advancing
Cancer Education

Reply To: To wait another two weeks or to start the therapy?

Dear Dr. West,

thank you so much for your feedback! I feel much better now knowing that my line of argumentation is not totally irrational. You have also calmed me down with your comment on the size of the liver lesions - my mom's "liver" blood values are still good. We can only hope now that the treatment with Alimta will go smoothly and bring some stability into my mom's disease. She really needs it...

My English is not the best, but please let me express my gratitude and huge admiration for the work and incredible efforts you are putting in here. I cannot imagine how you find the time to do all this plus your "normal" work at the hospital and can only hope that you also find time for yourself and your family! Thank you so much.

Best wishes,