Yesterday my husband had his 4th taxotere treatment. His first follow-up CT is scheduled for September 11th. We have been told since starting second line that as long as the follow-up CT doesn't show growth, that if it shows any shrinkage or stable disease then they would proceed with 6 treatments. However, if growth is shown then they would go to 3rd line with Tarceva.
Today my husband had some SOB after rushing up a flight of stairs and then went into what I thought was a panic attack with feeling he couldn't breathe etc and it snow-balled (so scary for him). His oncologist is away but the covering physician ordered a pulmonary angio to ensure he had not thrown a blood clot into his lung. The results came back negative for the blood clot, but in the verbal report the radiologist mentioned that the primary mass had grown 0.5 cm (was initially 7.4 cm). When the covering physician told us about this, she said she thought some minimal growth is allowed to be considered stable, said she thought the growth had to be above a certain % before it was considered 'ineffective treatment'. They are still planning on doing a complete CT series on the 11th (chest, thorax, abdomen, and pelvis).
So my questions are:
1. is there a 'magic %' of growth that has to occur before treatment is considered ineffective and is moved to 3rd line, or does that occur with any growth at all?
2. My husband never progressed while on Gem- Carbo first-line, he actually had significant shrinkage and was feeling the best he had in 2 years, but 2 months after he completed his 6 cycles, the cancer was found to be growing again. Is there ever a time that it would be appropriate to reuse one or both of those first-line drugs?
With thanks and appreciation,
Reply # - September 1, 2012, 07:19 AM
Hi believe, I know how awful cancer can make a wife feel and the symptoms can be quite devastating. I'm glad you can look at your husband and see he may be having symptoms of anxiety and not automatically think the problem is cancer. People tend to blame cancer on all the wild side effects assiociated with living with cancer. Truthfully, I've had some of those symptoms and antidepressants helps tremendously to diminish them.
I'm sure you won't be surprised to read that whether or not to move on to a new treatment depends of many factors. The fine line between progression and stable disease is one of them and needs to be weighed with other factors such as how well your husband is tolerating his current treatment.
Dr. West has said more than once on Grace something like if you have to squint to see the change it may not be a change worth stopping treatment for. It seems to come down to you want to get as much out of a treatment as you can before leaving it behind.
Below are 2 good links to blogs on stable disease.
Doctors don't usually go back to a treatment but everyone is different and if he didn't progress and it's been a while and if you've been through other treatments gemzar would be an option...but it depends. platman is probably not a good option though. It usually causes more problems a second time around than what it's worth.
I hope this helps,
Reply # - September 1, 2012, 10:36 AM
Janine really should have an MD after her name -- she provided a great explanation, along with the links that I think are helpful. Stable disease really isn't rigidly defined outside of a clinical trial setting. My inclination to continue a current therapy in the face of rather mild progression depends on all of these factors:
1) How much progression was there really? Relatively mild progression is well within spectrum of "stable".
2) How well is the person tolerating treatment? I'm more inclined to continue well-tolerated treatment.
3) Are there other attractive alternatives readily available? If so, I'm more inclined to move on than if we don't have good alternatives.
4) What is my estimate of the pace of the disease off of the treatment? Slow progression is worth taking if the alternative is much faster progression.
And Janine's very right about going back to the first line treatment. The convention has been to stop after 4-6 cycles and not look back, but the increased study of maintenance therapy has really illustrated that many patients don't exhaust the benefit of at least some of their first line treatment after that 4-6 cycle conventional limit. There's really good reason to not continue the platinum indefinitely: the two drug combination tends to lead to cumulative side effects faster than cumulative benefits, and ongoing platinum also has a good chance of causing a potentially severe hypersensitivity reaction over time.
I am increasingly inclined to consider returning to an agent that was stopped just because it was given for a fixed number of cycles rather than because the cancer progressed on it. But I'd be considerably more inclined to do that for a non-platinum drug.
Reply # - September 1, 2012, 11:55 AM
I just want to send my best wishes along to you and your husband. Having been through LC with my husband I know what a scary thing it is. I hope he gets good CT results.
Reply # - September 21, 2012, 05:52 PM
Thank you so much everyone. I apologize for my delay is responding. I did read your replies, but finding time to write a post just didn't happen. I continue to work full-time as my husband was self employed so now is without any income and without me working full-tIme would also not have the much needed medical benefits. In addition, we just moved our 'baby' away for first year University so we are empty- nesters and trying to adjust to that as well.
Janine, I agree with Dr. West. Your knowledge is incredible. Thank you so very, very much for mentioning that antidepressants helped you with your anxiety. My husband's anxiety continued to worsen over the next couple of weeks and became extremely debilitating. He has now been on antidepressants for 5 days and the improvement with the anxiety is significant already. Thank you again.
Dr. West, thank you so much for your reply. It really is so helpful and helps direct the questions to ask our own oncologists. We are celebrating though as the complete CT follow-up series done after my original post on the 11th reported stable disease, no growth at all! We met with the oncologist on Thursday on his chemo day and the plan he laid out includes one more Docetaxel on October 11th, for a total of 6 treatments.
I then asked about additional Docetaxel treatments as I have heard of 8 being given in some situations. His response was there was no evidence to support that in squamous cell stage 4 lung.
i then asked what next as stopping treatment makes me very nervous because growth occurred after 2 months of having finished the first-line cycles (of which the results had been excellent), and about the possibility of using Gemzar as a maintenance as he had good response on it as part of first-line. He indicated again, there was no evidence to support that and his recommendation is to go right to Tarceva. To not wait this time for growth but to use it as a maintenance so to speak? Your thoughts?
With thanks & gratitude,
Reply # - September 21, 2012, 05:54 PM
Lisa, thank you so much for your kind, supportive post. I like everyone here, truly hate this disease :(
Reply # - September 21, 2012, 07:49 PM
You are very welcome. I understand being busy and having a lot to deal with. Glad to hear your husband is seeing improvement with his anxiety and very happy to hear of his good CT results. Don't have anything to add about Tarceva except to wish you the best with whatever choice is made. Take care.
Reply # - September 21, 2012, 08:14 PM
I think your doctor's recommendation is based on the fact that Tarceva has been trial- tested as second-line and as maintenance treatment, and is FDA approved as second-line treatment, while Gemzar has not. And as Dr. West stated, traditionally one does not return to a first-line drug, especially if there are other good alternatives. And of course if Tarceva is not effective or becomes ineffective, Gemzar would still be a possibility.
Reply # - September 21, 2012, 10:24 PM
There is certainly some evidence for Tarceva in previously treated patients, while there really isn't any good evidence for Gemzar (gemcitabine) here. However, in truth, there is no evidence to necessarily stop Taxotere (docetaxel) in someone who is responding and tolerating it well, and most of the trials in this setting have actually continued it in the absence of progression or prohibitive side effects. I would say that there is slightly more (though admittedly weak) evidence to support ongoing treatment with a therapy that is associated with ongoing non-progression than stopping a single agent second line or later therapy after a fixed number of cycles.
Reply # - September 28, 2012, 08:05 AM
Jim & Lisa, thank you both so much for your responses (and I have to say I have done some historical reading on the site and your story warms my heart :)).
Dr. West, again thank you so very much for your response. I do know that my husband is tolerating his Taxotere, but definitely with each treatment the side effects are harsher & last longer. Strangely, he never lost his hair, his eyebrows thinned significantly and he rarely needs to shave and then only a spot or two, but he kept essentially a full head of hair (although it may be a bit thinner). The problematic side effects are the leg swelling, the neuropathy, fatigue and diarrhea. For him the neuropathy in his feet with treatment #5 has become the most problematic and the fatigue is almost debiliating at times. His performance status was rated at 90% at the beginning of second-line and this week it was rated as 70%-80%.
I did ask our oncologist the 'what if' my husband is unable to tolerate or does not respond to Tarceva. He said then he would look for clinical trials. I then asked if there were no clinical trials he was appropriate for as I know how specific the criteria is and he said in that situation as long as his performance status was still reasonable he would try eithe Vinorelbine or Gemzar as a single-agent but that since he had Gemzar as part of his platinum first-line with carboplatin he would go to Vinorelbine first. Your thoughts?
With thanks & gratitude,
Reply # - September 28, 2012, 09:02 AM
Hi Angela, I'm so sorry your husband is feeling the progressive effects of taxotere. I understand the thinking of neuropathy is that it too can become progressive. Has your husband tried lyrica (Pregabalin) or its precursors? They have been found to be helpful in this situation for many.
The standard thought about returning to a drug that has been used is to move on after using it. However, with the studies of maintanence therapies and the several years of its application doctors are more willing to go back drugs as long as the person didn't progress on it yet. In your husband's case Gemzer.
Neither Gemzar nor Vinorelbine have been studied as single agent second line drugs. Dr. West has stated that while drug companies don't normally fund reseach past getting FDA approval it isn't uncommon for doctors to prescribe either of the drugs for 2nd,3rd, etc. line of treatment.
On a personal note, my husband's onc stated that he felt going back to gemzar was a favorable option when my husband needs to move back to treatment because he's not progressed on it. Unfortunately the side effects were really wearing him down. The good side is it didn't and doesn't normally cause neuropathy. Navelbine (vinorelbine) can be extra hard on veins for IV use, of which my husband has very few left.
There really are so many threads on the subject (you may need to log off to access this list of search returns or to do a search yourself)
I hope this helps,
Reply # - September 28, 2012, 11:19 AM
I really think everything you're discussing makes sense. It's very common to have cumulative side effects become more problematic and eventually lead to a decision that ongoing treatment may be worse than the disease.
In terms of options, I've really discussed those that I think are reasonable in this link:
Because there's really no good trials that compare the options, I can't offer any meaningful suggestions that would suggest that one option is clearly better than another.