What's the next step for my mother, Cyberknife or other chemo drugs? - 1256122

12 posts / 0 new
Last post
qianyin
What's the next step for my mother, Cyberknife or other chemo drugs? - 1256122

I am writing for your advice whether my mother should get Cyberknife treatment. Some doctors suggested Cyberknife as a non-invasive treatment. But another doctor suggests wait-and-see, since the growth is slow. My parents are hesitant. They are concerned that Cyberknife may stimulate the growth of any residual cancerous cells if the ablation is not complete and things become even worse.

Below is a brief description of her history.

A 62-year old Chinese female, life time non smoker.
Multiple-spot nodes were detected in the right lung in 10/2005 when she was 54 during a regular body check-up, and confirmed through a biopsy as BAC in Nov. 2005. Surgery was not an option because of multiple spots.

11/2005 - 06/2006: 8 rounds of chemotherapy:
4 rounds of Gemzar + cis-Dichlorodiamineplatinum(II) + 4 rounds of Paclitaxel + Carboplatin (CBP).

One month after (08/2006), the growth of the tumors was detected and Gefitinib tablets (Iressa) have been prescribed by the physician since then. Iressa had been working well. The largest node remained the same and small ones shrank in size or disappeared from CT scans.

2011, cut Iressa dose in half.

However, the largest tumor was found to grow in 04/2012. She took four rounds of chemotherapy (Alimta/Pemetrexed disodium + Carboplatin) (11/2012 - 01/2013). The first two rounds seemed to work modestly, but the third and fourth didn't seem to work so she stopped the regimen.

Now she had increased Iressa to 1.5 tablets/day.

The present condition:

- The largest tumor is 52*35mm, and there are a few small ones.
- No metastasis is detected (by PET-CT, MR).
- All the results of blood laboratory tests are normal.
- CEA has been rising since 2008 (from 3.78 to 12.75 in 03/2013, dropped to 11.77 in 04/2013)

I have a couple more specific questions. Is her node size suitable for Cyberknife? Are there any targeted drugs that might benefit her?
Thank you for reading through. My parents and I will value any advice.

catdander
Reply To: What's the next step for my mother, Cyberknife or

QY, I very sorry your mother's cancer is growing.

If I understood correctly your mother has just one tumor. If so there is some practice of treating locally including cyberknife. Here is a blog post on the this subject. Note that there is quite a bit on the subject on Grace starting with the "further reading" at the end of the linked post, http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

Don't hesitate to ask follow up questions and let us know how your mother is.
Janine

Dr West
Reply To: What's the next step for my mother, Cyberknife or

Actually, it sounds to me as if there are several lesions being followed and that the largest is a little over 5 cm in diameter.

In the setting of disease that has multiple areas of active disease, I think it makes no sense to do any kind of local therapy unless there is just one lesion that is both growing at a significant rate and clearly outpacing other areas of disease.

For further information, I would recommend this post I wrote earlier this year:

http://cancergrace.org/lung/2013/01/20/mf-bac-algorithm/

Good luck.

-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

qianyin
Reply To: What's the next step for my mother, Cyberknife or

Thank you, Janine and Dr. West. I have read the post and relayed the gist to my mother. She has delayed the Cyberknife appointment and is going to see another oncologist on Monday.

Yes, there are several lesions and the largest one is a little over 5 cm. Is it very large for a lesion? It looks to me the lesion takes one third of the lung on some CT scans. I guess my question is how fast (or slow) of the growth is considered significant enough. I need to check with my parents with the numbers, but what I remember is the largest lesion increased about 2 mm in two CT scans spaced six months apart. Can this rate be tolerated? It has more than doubled from 2*2 cm2 when first diagnosed in 10/2005 to its present size of 5.2*3.5cm2. This is quite alarming to me. Another question is if Iressa stops working, will Tarceva still work? I read somewhere that a Japanese study showed if the patient responded to Iressa at the beginning, he or she has a high chance of responding to Tarceva even after Iressa is no longer working.

JimC
Reply To: What's the next step for my mother, Cyberknife or

Hello QY,

A 5 cm lesion is not small, but it's not always the size of the lesion, it's the rate of growth. And 2 mm in six months is pretty slow progression. As Dr. West often states, the rate of progression may be faster if a patient is taken off a generally effective EGFR TKI such as Iressa, so it may be that "bad brakes are better than no brakes," especially if there are no or minimal symptoms. He discusses this question here: http://cancergrace.org/lung/2012/08/05/acquired-resistance-faq/

There is some evidence that returning to an EGFR TKI that was effective for a significant period of time, or switching to Tarceva after Iressa has been effective, can provide additional benefit. You can read about that here: http://cancergrace.org/lung/2012/06/30/re-treatment-with-targeted-rx/ The standard dose of Tarceva is higher than that of Iressa, so that may be the reason that Tarceva could be effective even when Iressa has stopped working.

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>

Dr West
Reply To: What's the next step for my mother, Cyberknife or

There are certainly cases of response to Tarceva (erlotinib) after progression on Iressa (gefitinib), but that's still a minority of cases. It's more common to see prolonged stability for several months after this switch. If someone is showing growth only at a rate of a couple of millimeters over several months even before Tarceva, it's easy to envision that there could be stability for 6-12 months or perhaps longer with Tarceva on board.

-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

odossani
Reply To: What's the next step for my mother, Cyberknife or

Dear QY,

My own mother is in a similar situation (one large tumor outpacing the others but other small tumors with a little slow growth). We too have got different opinions from doctors (some in support of Cyberknife) and others who feel it may not benefit much. Yet others who think we can still "wait and see".

Based on Petscan activity we have decided to go forward and do cyberknife on the larger tumor (as the others have no activity on PET). Based on the fact the remaining tumors are on average ` 0.5cm it will hopefully be some time before they are going to become problematic.

However in your case there may an option to try Tarceva first and see if can do anything in addition to what Iressa did.

I will let you know how it worked out for us;

qianyin
Reply To: What's the next step for my mother, Cyberknife or

Hi, here I am with some mixed news. My mom did not try Cyberknife, but keeps on Iressa (1.5x regular dose). Good news is the Jun 4th CT showed no progression, everything remains the same. The concerning bit is CEA. It was 12.75 in 03/13, dropped to 11.77 in 04/13, but picked up in May, 16, and in Jun CEA increased again to 18. I know CEA is not a good indicator of progression, but its steady increase is unnerving to my mom and us. Could this mean some slow progression that is not detected on CT scans? The most two recent scans are in March and June.

My mom is considering an immunotherapy called DC-CIK. From what I understand, the doctors will culture the dendritic cells (DC) and cytokine induced killer cells (CIK) from the patient's blood for a couple of weeks and put them back into the patient. The CIK cells will then attack and kill cancerous cells. All information I can find is from China. Is this method ever tried in the US? I would like to hear Dr. West and other doctors' opinions on this therapy.

JimC
Reply To: What's the next step for my mother, Cyberknife or

Hello QY,

If there is a scan as recently as June which shows no discernable progression, the faculty here have consistently expressed the opinion that they would rely on the scan rather than a rising CEA level, and continue with a treatment that is tolerate well. In addition, Dr. West has said:

"There’s no question that we rely on and perhaps even obsess over scans in oncology. Imaging of solid tumors, looking for shrinkage or growth while on our treatment, is the most common yardstick for assessing how we’re doing. The trouble is that this can lead to too great a focus on the scan, so that we lose sight of the big picture, which is the care of the actual patient.

It’s not rare to have a situation in which our interval scans show a relatively minor change that you need to squint to see, but it may well lead us to overreact and make a change, because we’re predisposed to action, even when it’s just like changing lanes in a traffic jam and doesn’t get you anywhere any faster." - http://cancergrace.org/cancer-101/tag/clinically-significant-progression/

As far as DK--CIK, not much has been written here with regard to this therapy. A search of clinicaltrials.gov shows there are a few lung cancer trials which include cytokine induced killer cells (http://www.clinicaltrials.gov/ct2/results?term=cytokine+induced+killer+c... ), but each of them also includes the use of a chemo or targeted therapy agent. So relying on it alone has not been favored here in the U.S.

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>

Dr West
Reply To: What's the next step for my mother, Cyberknife or

I'm really glad to hear she's doing so well, even if she and her oncologist have come to the conclusion that she's progressing based on essentially no evidence of that. I think her case is a good illustration of why smart oncologists are so wary of using CEA levels for lung cancer. I couldn't be less inclined to change treatments based on a CEA level alone, combined with stable scans and a patient doing well clinically, and I would consider the CEA variation you describe to be about the least alarming pattern I could imagine, short of it continuing to decline. It suggests to me that too many people are inclined to change things just for the sake of making changes...looking for trouble as hard as possible, even manufacturing it when it isn't really there.

As for DC-CIK, it sounds like a reasonable premise, as we gain more evidence that some immunotherapies may be helpful for lung cancer, among others. But I don't know of any specific work on this approach and would consider it a very reasonable strategy in the setting of a clinical trial, but misleading to consider it remotely beneficial yet. I have never heard of this strategy among North American oncologists, and I'm essentially 100% certain that any truly effective lung cancer treatment would be known outside of China. I suspect it's an approach that is being marketed far outside of any evidence that it's actually an effective treatment just yet.

-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

qianyin
Reply To: What's the next step for my mother, Cyberknife or

Thank you, JimC and Dr. West.

My mom's oncologist actually suggested "wait-and-see", but my mom, as she is, wants to feel she is still in control, at least to some degree. We also want to know if there are any other options should the progression get faster.

Perhaps my question should be: in US, what are the second- or third-line treatments for patients who have responded to both traditional chemo (Gemzar/Paclitaxel/Carbo) and Iressa, but developed resistance later? There are few (well-regulated) clinical trials in China, especially on targeted therapy, and they are usually 1-2 years later than in US, but we can try to find out.

Thanks again,
Qian

Dr West
Reply To: What's the next step for my mother, Cyberknife or

The established treatments after chemo and an EGFR inhibitor (Tarceva in the US) are Alimta (pemetrexed) and Taxotere (docetaxel). Other chemo agents, such as Navelbine (vinorelbine), are sometimes given, but with no established benefit.

There are no established treatments that are effective in prolonging the benefit from EGFR inhibitors once acquired resistance develops.

-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