Wife Update - GOOD NEWS! - 1248810

Hi Fides,
That is fantastic news!. How relieved your household must be. A small loculated plural effusion that isn't causing any trouble is normally left to heal itself and isn't usually a reason to stop alimta if side effects are minimal. Also chemo is thought to help dry out effusions. What does her onc say.

I'm not a medical professional so we should check to see if Dr. Weiss can give us further input.

Again CONGRATULATIONS ....... I hope y'all are able to celebrate the good news.

Janine

Pemetrexed works by inhibitting the metabolism of folate, which is needed by cancer cells, in several different ways. It is an improvement on an older drug called methotrexate. High quality data show that methotrexate can accumulate in fluid collections and cause problems. Based on this shared mechanism, there is a theoretical concern that pemetrexed can do the same thing. Some very smart doctors question whether this is real, but I have seen it and have heard stories of it from other docs. However, it is also rare. In practice, small fluid collections rarely cause this problem. Further, it's a problem that you can monitor by monitoring blood counts and kidney tests (creatinine). In practice, I don't at all consider small efussions to be an absolute contraindication to pemetrexed.

With all that said, and a deep breath, that doesn't mean that a patient who's had a great pemetrexed response and has received many cycles of therapy, couldn't consider a break. In clinical practice, we routinely give brief breaks when such patients want to travel somewhere or do something. Further, we comfortably stop (until proression) a second line drug like pem after many cycles and good response in patients who are having cumulative side effects. The truth is that after a large number of cycles, we don't really know how much benefit additional drug will or won't provide.The harder decision is for a patient without cumulative side effects. Here, my bias is that if the treatment is working, and there aren't cumulative side effects, then I favor continuing it for the possible benefit that may come from continuing it.

Of course, most patients have an opinion on the subject and that's very relevant. Some patients badly want a break; I endorse it since I don't know if more cycles really will help. Others would feel anxious if they stopped; for them, I continue as there may well be benefit to more cycles.

Hi Dr. Weiss:

Re: the issue of pemetrexed (alimta) accumulating in fluid collections and "causing problems" - - in your experience does this issue generally resolve itself once pemetrexed has been discontinued (and overtime), or does this issue remain longitudinally despite stopping the drug?

Thank you,
Laya

P.S. Just as an FYI. . .as you may recall, my Mom is a right pneumonectomy patient who never really accumulated any fluid in the right cavity until about 2 years post surgery due to a bronchoplueral fistula in the right main bronchial stump. A few months ago, while my Mom was on carbo-alimta and then just alimta, the fluid suddenly started accumulating and some would go through the fistula into her main bronchus causing her to aspirate and cough. The alimta was stopped. a few weeks later the fluid in that cavity was drained via a thorocentisis and it was a really weird color. It was serro-sanguenous, but milky. Almost looked like an infection, but it wasn't infection. The doc doing the procedure commented that it was a really weird color. The pathology on the liquid came back with no cancer cells detected, no infection, and also commented that the liquid was very strange. There were some inflammatory cells in the liquid. Anyway, we are now about 10 weeks out from her last Alimta treatment, and the liquid they are draining looks like a reddish gatorade (you can see through it). So, based on what you have written, I'm wondering if the original draining (which was over 800 ccs) was the color and consistency that it was because of Alimta collecting in it. I'm also wondering if the sudden onset of this effusion is related to Alimta and that now that Alimta has been stopped, it will dry up. Anyway, thank you for your anticipated response to my above question.

I'd like to ask about something Dr. Weiss said about stopping Alimta (until progression) after many cycles and a good response in patients who are having cumulative side effects. Are there stage iv patients who don't have progression after stopping maintenance treatment? Is there an average time after stopping treatment that you expect to start seeing progression?

My sister-in-law just had her 51st treatment of Alimta/Avastin and considering stopping treatment because there has been no sign of cancer for more than two years. During that time she's had multiple PET/CT scans and a needle biopsy. We know she can go back on treatment if there is progression but it would be nice to hope that maybe she won't need to, even if it is just a very small chance. She's tolerated treatment well so that's not the reason to stop. Our concern is more about long-term effects.

Finally, how often are patients who stop treatment scanned and for how long? I assume initially it's fairly frequent, but does that change over time?

I realize there are no definitive answers about this, but am wondering what doctors are seeing and hearing as more stage iv patients stay on maintenance longer with good results. My sister-in-law can't be the only person like this.

Thanks

Yes, there are definitely patients who get chemo, take a break, then have no progression for a long time. I just saw a patient who got 4 cycles of chemo and had about a year of progression-free time off chemo before her cancer started growing again.

Hi Dr. Weiss - -

I was wondering if you also could respond to my question above (the one above mk619's). Thank you.

Laya