What after Carbo-Alimta and Alimta maintenance do not work anymore? - 1264023

Fri, 05/23/2014 - 19:07

Last week’s CT scan showed GG nodule had increased from 1.3 to 2.0 cm, another GG nodule was stable. Recurrence followed 4 months with Alimta maintenance every 4 weeks, followed mid February by a hiatus of 6 weeks before going on the 4 cycles of Carbo-Alimta.

Q: Could the hiatus of six weeks have contributed to the growth?

We may need to look at a 2nd line treatment. There is a phase III open label clinical trial where Roche's MPD3280A (ANTI PD-1L) is being compared with Docetaxel (NCT02008227) for patients with NSCLC after failure with platinum-containing chemo. Docetaxel is generally the preferred 2nd line of treatment. Immune therapy (PD-1L) is currently getting a lot of attention.

Question: Is this the best/most obvious clinical trial for mBAC patients who do not respond anymore to Carbo-Alimta and/or Alimta?

Would appreciate feedback from anyone familiar with this dilemma, how it was resolved, with what result, i.e., which other line of treatment like e.g., gemcitabine or navelbine.

My wife has BRAF V600E mutation. GSK's dabrafenib (Tafinlar) received Breakthrough Therapy designation for patients with metastatic BRAF V600E. Her cancer has not spread beyond her lungs.

Question: Anyone out there with mBAC - BRAF positive treated with dabrafenib?

My wife, 67 yrs.
Mar 11 lobectomy left LL & lower UL.
Scans: May 11 clean; July 11 bilateral GGOs; Sep 11 more prominent GGOs;
Feb 12 PET scan further growth, no mets, BRAF positive (V600E)
Mar 12 Carbo-Alimta chemo
Apr 12 CT improvement
Jun 12 CT continued improvement
Alimta maintenance
Sep 12 CT stable
Jan 13 CT improvement
May 13 CT stable
Sep 13 CT stable, Alimta now once every 4 weeks
Jan 14 CT stable but new 1 cm GG nodule
Feb 14 CT GG nodule increased to 1.3 cm and a small on of few mms; if BAC was primary malignancy findings concerning for recurrence. Going on 4 cycles of Carboplatin-Alimta.
Mar 14 PET GG nodule has max SUV of 1.4.
May 14 CT GG nodule has grown to 2.0 cm

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Dr West

I'm sorry that the most recent scan demonstrated this progression, though it is rather slight.

To address your question, I think it's unlikely that interval of just a few weeks off led to the increase in the nodule. It's far more likely that the progression occurred some time in the much longer interval during which she was on treatment. But there should be several interval scans showing what has been happening along the way. It hasn't been 5 months or longer since her last scan, has it? You generally don't go more than 2-3 cycles of chemo at a time without checking whether the scans are showing improvement or not.

Yes, the best evidence after a carbo/Alimta (pemetrexed) and maintenance Alimta regimen would favor either Taxotere (docetaxel) or possibly Tarceva (erlotinib). An immunotherapy approach is certainly a very strong alternative, but this would still be an investigational approach compared with Taxotere or Tarceva.

I don't have personal experience dabrafenib.

Good luck.

-Dr. West


Dr. West,
Appreciate your feedback.
To be more precise the Sept-13 scan showed no GGO. At that time she went from every 3 weeks to every 4 weeks Alimta.
Early Jan-14 scan showed new 1 cm GG nodule.
End Feb-14 scan showed the nodule now to measure 1.4 cm. Another GG nodule was seen 1.1 cm against a few mms previously.
A mid March-14 PET scan showed the GG nodule to be 1.3 cm (1.4 SUV).
The mid May-14 scan showed the nodule now to measure 2.0 cm, the other nodule measured now 0.7 cm, so that one seems to have shrunk.
Mind you, all these scans are read by different radiologists which may cause less precise interpretation of what is being measured I would think.
My thoughts are that while we are going through the process of determining the way forward she goes on Alimta maintenance again (every 3 weeks) and do another CT scan in two months. If that scan confirms further growth then we should go with a second line, be it Taxotere or the indicated trial.
Are there any data to suggest that BRAF mutation positive patients do respond well to Tarceva?
Again, we are most appreciative of the work you do.

Dr West

I don't see a value in continuing a treatment on which the cancer has been progressing for months. The bone marrow has a finite reserve to regenerate new blood cells, and I am wary about wasting that marrow reserve on a treatment on which the cancer is clearly steadily progressing. Radiologist interpretation wouldn't explain a change from 1.3 to 2 cm over two months -- that's just clear progression. I would be skeptical that the Alimta is doing anything right now.

There are no data to suggest that BRAF mutation positive patients respond better or worse than anyone else without an EGFR mutation.

Good luck.

-Dr. West


Luke, Thank you so much for jumping in here. It's important to understand there's clinical research being done on mutations other than the ones that have approved treatments; EGFR and ALK and ROS.
We need to hear about people like your dad doing well on novel drugs in trials.
I hope he continues doing well a long long time.