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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.

Tales from the Clinic: Anne S and her Indolent Metastatic NSCLC
Mon, 12/29/2008 - 19:44
Author
Howard (Jack) West, MD, Associate Clinical Professor, Medical Oncology, Executive Director, Employer Services, Founder, President and CEO of GRACE

Let's return to what happened with Anne S., who I introduced in the last post. The highlights are that I met this woman in September of 2005, when she was 79, slowing down from many medical issues unrelated to cancer, wary about chemo, and with a cancer that was metastatic but that had progressed only minimally in the months between the initial detection of her cancer and when I first saw her. We agreed that attentive follow-up made sense.

And so, I saw her regularly, and her scans showed very minimal progression 6 and 12 weeks after her initial visit with me. She also felt pretty much the same, bothered primarily by her arthritis, fatigue (which preceded her cancer), and other issues...but no appreciable decline. In fact, she didn't really show very convicing progression until late May of 2006, when one liver lesion grew pretty notably, and a new one emerged. We again discussed the risks and benefits of treatment, and she decided to start single-agent gemcitabine (navelbine is a well-studied option in the elderly, and it's a fine choice I've also given frequently in similar situations, but it does have the inconvenience of generally needing to have a port-a-cath placed, because it can cause a chemical burn if it leaks out from the IV catheter into the surrounding tissues).

I followed her closely, since I needed to prove to myself and her that she could do well with it. In fact, she said she barely felt it, and at some visits she said she actually felt that her energy level was better than before chemo. This may have been because of the beneficial effect it was having on her cancer, which showed a slight amount of shrinkage at her first scan after two cycles, and a more convincing response after two more cycles. She was happy, and we continued chemo for several more months, though we decreased the dose of gemcitabine from 1000 mg to 800 mg, two weeks out of three, because her white blood cell count was flirting with a concerning range, and she was getting a little more tired.

She continued to do well overall on this regimen, with stable scans and no new symptoms, until January of 2007, when we decided to give her a break because she was moving to an assisted living facility and felt like she could just use a break. It wasn't as long as she would have wanted, since we restarted gemcitabine after her scan six weeks later again showed mild but convicing progression. So it seemed that the gemcitabine was probably doing an effective job controlling the disease, and we restarted it in late February. After two more cycles, her scans showed pretty much stable disease (some stable lesions, a few hints of tiny progression, and a few areas of minimal shrinkage). By then, however, she was interested in trying an alternative approach, namely tarceva, since she knew of a friend of a friend who had done well with it. With her history of having quit smoking 40 years earlier, I thought she might do quite well with it, though I had been inclined to recommend more chemo because she had responded well and for a long time on first line chemotherapy.

She started tarceva in April, 2007, which she tolerated well, with just modest dry skin and a typical rash, as well as some loose stools that were quite manageable. Her CT after two months of tarceva showed a mixed response, specifically with a clear minor response of the disease in her chest, and the liver lesions either stable in some areas or growing slightly in others. We decided to continue it for another month, when the progression in her liver was quite convincing and not accompanied by any shrinkage elsewhere.

She started Alimta in early July of 2007, and she again tolerated chemo well, saying she thought she felt better on it than off. After two cycles, we were thrilled to see a very good response of the cancer in both her liver and her chest, and she continued on it for many more months. Later CT scans continued to show further minor shrinkage, and we increased the interval between scans from every 6 to every 9 weeks because she was doing so well. She continued to show completely stable results for several more scans, and by May of 2008, she began getting a little more tired and requested another break from treatment.

A follow-up scan in late June showed progression that was barely perceptible, so we continued to watch her off of treatment until October, when her scan again showed some progression. Incidentally, she didn't feel any real change in her fatigue and became increasingly convinced that chemo wasn't really a culprit. By October, she again had some mild progression in her liver, so we restarted Alimta. Over the past few months, she has continued on it as if it was barely a speed bump, now an old hand at this. Fortunately, her last scan in late November showed a minor response again. And so the story continues, with her on alimta and feeling generally well. She actually just completed a cardiac workup and had a pacemaker placed last week, after which her she found that her long-standing fatigue was definitely improved. So now I'm going to have all of my patients who report fatigue on chemo get a pacemaker implanted, just in case that's the source (just kidding).

There are a few take home points here. First, she's now 82 and approaching 3.5 years from her initial diagnosis and going strong, feeling better on some days than she did then. She clearly has a more indolent cancer than most NSCLC, but it's progressed convicingly off of treatment, and it's responded to chemo on multiple occasions. And she's tolerated it well, despite the fact that she is now 82. This treatment plan has included breaks along the way and overall deviates from the general rules for NSCLC, which don't include following untreated patients with advanced NSCLC before starting chemo, or stopping chemo here and there along the way. But every clinic has real life cases that deviate from the guidelines and strategies I describe here. I just wish we had more patients who were doing as well as Anne.

I'll plan to describe several other interesting and informative cases as well -- some success stories, and some less so. But all potentially helpful.

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