We know that cancer cells mutate over time -- in fact, that's how they became cancer cells. In fact, oncologists see the heterogeneity of cancer cells in our daily practice every day. Although there are certainly many reasons why patients have some of their cancer cells respond and others not (blood supply, local microenvironmental factors, etc.), one of the important factors is genetic heterogeneity within the cancer cell population -- some cells die and others don't.

Several weeks ago, I described the results of a survey I sent out to several colleagues who are lung cancer experts around the country, asking how they would manage a case of a newly diagnosed Caucasian never-smoking patient with advanced NSCLC, adenocarcinoma, and asymptomatic subcentimeter brain metastases, treated with whole brain RT before starting systemic therapy.

A few weeks ago I described a blood test for predicting survival after getting an oral epidermal growth factor receptor (EGFR) inhibitor that is just becoming commercially available. This is called the Veristrat test and from company called Biodesix.

Here's a video slide presentation that provides a basic introduction to bronchioloalveolar carcinoma (BAC), including the demographics, natural history, imaging appearance, and patterns of response that make it a unique subpopulation within lung cancer. The audio only version is below the video.

One of the general rules in oncologist is that we typically use our most effective treatments first, and often early, though there are certainly exceptions. Women with metastatic breast cancer may have a higher response rate by receiving combination chemotherapy than single agent chemo, but when a gentle single drug chemotherapy or hormone therapy option will do very well and provide fewer side effects, that’s usually the approach we recommend until bigger guns are needed.

Several years ago, we learned that EGFR tyrosine kinase inhibitors (TKIs) were not a very helpful strategy for an unselected population of frail patients in the US, clearly inferior to standard chemotherapy (see prior posts here and here).

About 18 months ago, I wrote a post about a new technique being developed that looks at the pattern of proteins in the blood of a patient in order to determine whether a patient is likely to do well or poorly after receiving an EGFR tyrosine kinase inhibitor like tarceva (erlotinib) or iressa (gefitinib) for advanced NSCLC.

One of the basic concepts of oncology is that you treat patients with different drugs once they've shown progression on a treatment, rather than continue that a patient has presumably become resistant to. However, there are some exceptions to this: many or most women with breast cancer continue the antibody herceptin (trastuzumab) even after progression, adding it to one chemo and then the next, and the same is often done with avastin in colon cancer and sometimes lung cancer as well.

Our tendency in oncology is that once we find a new active drug in cancer, we try to add it to our current standard treatment approach and see if we can do better than what our current standard achieves. More is better. And we knew that the epidermal growth factor receptor inhibitors Iressa and Tarceva could lead to significant shrinkage of some lung cancers. So the lung cancer community was relatively optimistic about the clinical trials that compared chemo alone to the same chemo with Iressa or Tarceva.

NOTE: ALL FIGURES CAN BE SEEN BY DOUBLE-CLICKING ON THEM, EVEN THOUGH NOT ALL APPEAR AS THUMBNAIL VIEWS PROPERLY.