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Dr. Jack West is a medical oncologist and thoracic oncology specialist, and Executive Director of Employer Services at the City of Hope Comprehensive Cancer Center in Duarte, CA.

Clinical Cases: 79 Year-Old Woman with an Indolent Metastatic NSCLC, Part 1
Sun, 12/28/2008 - 06:15
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

In addition to the presentations about the evidence, I thought it might be helpful to highlight some of my own clinic cases that can illustrate how I use the principles in practice. These cases should highlight that many if not most people don't exactly follow the "classic" example, and that if we were to open the case files from most oncologists, we'd find that it's very common (and appropriate) to bend the guidelines, to individualize based on the particular issues of a specific person. And I think it may also be helpful to see the range of what's possible. I'll plan to cover not only the patients who do far better than average, but also will discuss some other cases that have illustrated the harder aspects of lung cancer. There's a great spectrum in how people do, and we'll provide a glimpse of that spectrum.

I'll start with Anne S., a truly delightful woman who came to me in September of 2005 with metastatic NSCLC and still seeing me today, and feeling as well as she did then (so you know that this is a relatively happy case). I'd like to say that this is because of her brilliant oncologist, but I think her case largely illustrates how indolent metastatic lung cancer can be, particuarly in some elderly patients. If there is an element that I think I was able to manage well, it's that we haven't over-treated her along the way, with a cost to her quality of life.

Back in August of 2005, I met Anne when she came for a second opinion about her newly diagnosed advanced NSCLC. She was 79, had previously worked for the state and also in real estate, and had quit smoking about 40 years ago after previously smoking about a pack per day for 20 years. Importantly, she had several ongoing medical problems, including atrial fibrillation for which she was on coumadin, osteoporosis, a prolapsed bladder, and some other things. She had also had a series of falls over the past year or two, one of which associated with a severe bleed from her liver (likely because she was on blood thinners). In that hospitalization, which was in January of 2005, she had a CT that incidentally showed a left upper lobe (LUL) mass just under 4 cm, a few enlarged mediastinal lymph nodes, and a possible metastatic lesion in her liver. Because she had more acute medical issues to attend to, the workup of this possible cancer was put on the back burner until she recovered from her injuries. In August, a repeat CT scan showed that the LUL mass had grown by about 1-2 millimeters, and that there were probably a couple of liver lesions. All of these areas, including the LUL mass, the mediastinal nodes, and the liver lesions lit up on the PET, with an maximum standard uptake value (SUV) in the 5-8 range. A CT-guided core biopsy showed a moderately to poorly differentiated NSCLC with adenocarcinoma features.

She then saw a very good medical oncologist in my region, who talked with her about starting carboplatin and taxol, which is a very reasonable and arguably optimal approach. Despite her age of 79 and other medical problems, she was feeling very well and limited in her activities just by a slight and general slowing down, but she was pretty sprightly and wouldn't necessarily need to be treated less aggressively than standard platinum-based doublet therapy. But she was wary about chemo, and her cancer demonstrated only minimal progression over more than 6 months of follow-up before starting treatment.

I explained that we could start with treatment now, but I felt comfortable following her off of treatment until she showed convincing and clinically meaningful progression of her cancer. She was pretty skeptical of the benefits of chemo for her, as well as concerned about detracting from her quality of life, so she was more than happy to hold off, see me regularly for follow-up visits and scans, and consider treatment more carefully if or when we saw evidence of progression.

Importantly, the grade of her cancer (moderately to poorly differentiated) and the PET uptake (the higher single digits) were not especially suggestive of extremely indolent cancer. I would have been more confident of the lieklihood of needing no treatment for years if the pathology showed a well to moderately differentiated cancer and the pET SUV was under 5 everywhere. Nevertheless, I've previously written that the clinical history trumps these other correlative findings (prior post here), and the extremely minimal progression over more than 6 months strongly suggested that this cancer just wasn't going to progress wildly between 6-8 week visits.

Her cancer wasn't so indolent that we could go without treatment for years, but we were able to go for many more months before revisiting treatment. She has received several lines of therapy over the last 3+ years, and we'll cover what she received and how she did in the next post.

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