Watch and wait approach vs. treatment options - 1274699

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patsgirl68
Watch and wait approach vs. treatment options - 1274699

I'm reading on here that sometimes waiting is the best treatment. But what defines when you should no longer wait?
My mom's history:
In July of 2013, an abnormality was spotted in a chest xray, after pnuemonia. In a PETscan, they confirmed a small nodule in her right lung that was definitely cancer, and then there were a lot of "little sparkles" throughout both lungs. She had a biopsy of the nodule and it was confirmed to be adenocarcinoma. Mom switched her care to Roswell Park, had another biopsy of the left lung where the ground glass "sparkles" were, (which came back inconclusive/negative). In October 2013, she had 2 wedge resections of her upper and lower right lobes (removed 3 nodules, 1 with a tiny margin) and they checked out her lymph nodes in the chest (one was calcified, but none were cancerous). The surgeon said her kind of adenocarcinoma is an old subset they no longer use (BAC) which is a multifocal adenocarcinoma with limpidic features. They staged her at IIb and EGFR positive. She went thru 4 rounds of chemo (Cisplatin/Alitma), ending in Feb 2014. .All was quiet for a while and every 3 months we were told NED. Back in October 2015, the oncologist said there was an area they were watching in right lung and it was tiny. He didn't really give us too much more, just that if it grows they will biopsy it. In February 2016, he said there was very little change and extended the next appt to 5 months. Went back this month and were informed of 3 nodules. One is 8 mm, one is 9 mm and one is 5 mm. All slowly changing. All have grown since October (anywhere from 1-3mm from what I gathered from seeing the scans.
The plan is, in 2 months she goes for a PET scan, to confirm and figure which nodule is good to biopsy and they will retest it for genetic mutations. They have talked about Tarceva for treatment but nothing is definite.

Its small and slow growing, but treat or wait?

JimC
Hi patsgirl,

Hi patsgirl,

Welcome to GRACE. Although pathologists have changed the name of BAC, experts in thoracic oncology still tend to use the term, mostly out of habit and ease of terminology. GRACE's Dr. West is one of the leading experts on BAC, and he always stresses that it should not be over-treated. He has devised an algorithm to assist in making treatment decisions, which you can find here.

Your mom's BAC has been relatively indolent, so the question at this point is whether there has been "significant interval change in imaging and/or symptoms". A good argument could be made that 1-3 mm growth over nine months is pretty slow, warranting a continued watch and wait approach. In terms of BAC, as Dr. West states in the referenced post: "much of it is very slow growing and among the least threatening cases ever labeled as lung cancer." He goes on to state:

"People with a very slow growth rate are likely to do very, very well no matter what treatments they get, as much despite as because of those treatments. In many cases, interventions are pursued on patients who are destined to do very well, and then when their short term survival is good, the people who did that intervention write a paper saying how their approach is feasible and attractive because the patients did well — not recognizing, or at least glossing over the idea, that they were going to do very well anyway.

I would say that in no other area of lung cancer care is it more important to distinguish between what can be done and what should be done. And the real experts know when to not intervene."

If progression is deemed significant enough to initiate treatment, the algorithm show that the presence of an EGFR mutation would make Tarceva a good option for systemic therapy.

Good luck to you and your mom.

JimC
Forum moderator

<p>I began visiting GRACE in July, 2008 when my wife Liz was diagnosed with lung cancer, and became a forum moderator in January, 2010. My beloved wife of 30 years passed away Nov. 4, 2011 after battling stage IV lung cancer for 3 years and 4 months</p>