Whether to have chemo after radical radiotherapy? - 1248705

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Whether to have chemo after radical radiotherapy? - 1248705

My mum was diagnosed with NSCLC Squamous in July. She had a 10.5x7cm tumour in her left lower lobe and 2 enlarged lymph nodes on the same side as the tumour. The tumour was also impinging on the pericardium. For this reason, we were told surgery was not an option and only pallaitive chemo could be given.

We sought a second opinion and found a wonderful oncologist. He firmly disagreed on the pallaitive route! My mum is 58, incredibly well (only had a cough) and no spread to the rest of the body (She had a PET scan). He agreed that mum's tumour was too large for radiotherapy at that stage but that if the chemotherapy was successful at shrinkage, he would want to give my mum radical radiotherapy with intent to cure! We went away focussed on this.

Well Mum's had a fantastic response to Chemo (cisplatin/gemzar)! After first round, her tumour had shrunk to 7x5.5cm and the lymph nodes were now 1cm and no longer considered significant. Cough disappeared. She's now just finished her third round of chemo and the tumour is now 5x3.5cm!!! And well clear of the heart and pericardium. We are thrilled. The 2nd oncologist we saw now wants to start radical tomotherapy 5 days a week for 6 weeks - with intent to cure. He says Mum will not need anymore chemo after this radiotherapy as research has shown no benefit in having extra Chemo. He is confident with using the radical radiotherapy to eradicate the rest of the cancer. He says mum has a 30% chance of cure. She will be monitored.

The original (pessimistic) hospital has now changed it's tune after Mum's great response. They now say they would also give her radical radiotherapy (not tomotherapy) but they feel an extra round of chemo after this is essential (they haven't backed this up though). They use the sandwich technique.

Can you please give me your opinions? Would you give my mum further chemo after this radical radiotherapy? Or would that be putting her through more chemo unneccesarily. Many thanks for your help.

Dr West
Reply To: Whether to have chemo after radical radiotherapy?

It's great that she has responded so well. I'm afraid, however, that judgments about more chemo are really a matter of opinion and not good evidence to guide us. Because of that, I can't say what I would do, and I don't think any perspective is more than just a judgment without enough evidence to clearly say what to do. I'm sorry it's not possible to give a real answer, but the truth is that there is no evidence that more chemo is better, so you're left with a situation in which it's really a philosophical issue about whether to presume more is better and do it, or to say that in the absence of evidence to support it, more shouldn't be given.

-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

Reply To: Whether to have chemo after radical radiotherapy?

Congratulations on your mum's excellent response and for the hope of cure! That's so terrific. So glad for you all.

The term radical radiation is different from anything I've heard. When giving radiation for curative intent it's given between 60 and 66 gray as Dr. West noted below (it's what my husband got as he was also considered curable). When giving radiation to shrink a tumor so a person is more comfortable you don't need as much. But your mum's was at a curative amount...semantics. The tomotherapy probably wouldn't matter in a situation where you want to kill all viable cancer in the chest because it's ok for the tiny bit of scatter a normal radiation machine may give because it may get a bit of scattered cancer.

As for your question about the extra chemo. This is the most controversial stage in terms of treatment, in other words there may not be a good answer and good doctors can have differing opinions here. Normally, they would have liked to give the radiation and chemo together. But chemo was needed to shrink the tumor away from your mum's pericardium before they could radiate it.
One way to look at it is there is a limit to how much platinum a person can take before it becomes too toxic. 6 cycles is considered to be that limit. If she hasn't met that limit and if your mum and her doctors feel she can handle it then it may make her feel she has done everything possible.

From your previous thread, "In terms of how to approach patients who aren’t ideal for surgery but still have regionally localized and potentially curable NSCLC, chemo and radiation are ideally combined and given concurrently, with radiation given to a full, definitive dose of at least 60 Gray (Gy, the unit of radiation dose) and often more like 64-66 Gy (most typically given once daily for 6-7 weeks)." http://cancergrace.org/topic/stage-3ab-do-lymph-nodes-need-to-be-clear-b...

So much depends on situation, style, and personality.
forum moderator

Reply To: Whether to have chemo after radical radiotherapy?

OK, Dr. West answered while I was trying to fit my long answer into the number of characters allowed per post. But I'll leave it.

Congrats again. and sorry for the decisions y'all will need to make. They are always difficult but in the end most people feel much better once made.