When to start with Xalkori - 1250007

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When to start with Xalkori - 1250007

Dear Cancer Grace,
I am a new memeber and would very much appreciate your help on one topic:
On January 2012 my mom (54) was diagnosed with poorly differentiated adenocarcinoma of the lung stage IIIB or IV (not sure since docs in Croatia don't tell exact staging, her mets are only on lymph nodes including lymph nodes in her neck). She went through 6 cycles of chemo (gemzar/cisplatin) ended 30.5.12 and since then she is off the chemo as she is stabile. Cancer is there but there is no progression. In the meantime she was tested for Alk + and result is positive. We wanted her to start with Xalkori but Onc said that we should wait with Xalkori until progression starts then recently he changed his decision so she should probably start within 10 days. Anyway I would kindly ask for your opinion on this, should we or should we not wait for progression of disease before starting with Xalkory? The cure has lot of side effects so we would really appreciate your advise on this.

Many thanks!


Dr West
Reply To: When to start with Xalkori

There is no right answer to this question. We absolutely want to ensure that any patient with an ALK rearrangement has a good opportunity to benefit from XALKORI (crizotinib), since it can be so effective, but we also know that its beneficial effects don't last forever. Because of that, I have typically favored waiting until there is some meaningful progression, and potentially also some symptoms related to the underlying disease, before "starting the clock" on the treatment and the resistance that follows over time. The concept of delaying treatment is based on not wanting to use any treatment before it's really needed, and not wanting to develop resistance while a patient wasn't even needing any treatment at the time.

The potential downside is that a rare patient may have a catastrophic change that drops their performance status and makes them less likely to benefit from a targeted therapy that was quite likely to help. Something like a sudden appearance of multiple brain metastases or leptomeningeal carcinomatosis or a huge pulmonary embolus (blood clot in the lungs) could possibly cause a patient to go downhill in a hurry and not benefit as much from the targeted therapy that otherwise might have been so helpful.

In conclusion, I don't think there's a right answer here. The odds are very good that the XALKORI (or an EGFR inhibitor in someone with an activating EGFR mutation) will be effective now or later, and I think there's good reason to wait on starting a treatment until it's likely to provide the most benefit, if it won't be effective forever. On the other hand, there is a very small but real risk of missing the chance to really benefit because some intervening new serious issue develops.

The only other point I'd make is that most people taking XALKORI don't experience significant side effects at all. If you read official paperwork, every drug lists endless potential side effects, but that's partly legal posturing.

-Dr. West

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

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