DrWest

FYI for anyone living in the Pacific Northwest, the Global Resource for Advancing Cancer Education (GRACE) is offering a free live program this coming Saturday afternoon. It features national lung cancer experts who will be there to provide brief talks on key topics in NSCLC management, as well as panel discussions of several cases. Registration is free but requested, since space is limited. More information is provided here: http://cancergrace.org/lung/2009/08/12/ ... duc-forum/ Take care, Dr. West

I just wanted to add that Ned's point about no really being able to "downstage" is more or less how we approach things. I say "more or less" because the docs also want to give the patient the benefit of the doubt. I'd say that we couldn't be as optimistic about a treated brain metastasis isn't the same as LD-SCLC, but it ay stll be feasible to treat aggressively and with curative intent. That would mean adding chest radiation along with chemo, and I would definitely give prophylactic/whole brain radiation -- SCLC has a very significant tendency to spread to the brain, and we fear that where there's one visible, there is often more that we can't see. I've written a post on the OncTalk website about the chance for more favorable outcomes with a solitary brain met: http://onctalk.com/?p=437 However, the majority of such cases have been in NSCLC, which has less of a tendency to early spread than SCLC. Still, I think it's fair to have some hope that this will be a better situation than multifocal metastatic disease that is, unfortunately, much more common with ED-SCLC. -Dr. West

Paperback, Katie was very kind to recommend me and OncTalk. You can certainly find a lot of information that I hope would be helpful there, but I'd recommend this particular post that might apply for your mother, if she's lucky: http://onctalk.com/?p=437 Good luck. -Dr. Jack West

I just found that a patient developed rather signficant hypothyroidism (low thyroid activity) after a few weeks on Sutent (clinical trial for never-smokers and patients with BAC). Interestingly, on the schedule of 4 weeks on and then 2 weeks off therapy, her symptoms and thyroid function normalized during the "off" period, just before she saw me and an endocrinologist in follow-up. I suspect her thyroid will shut down again back on sutent (she's on a low dose of thyroid replacement now, and we expect it will be a moving target). I also suspect that if we checked thyroid function more in patients we'd find that hypothyroidism, likely from our treatments, is more common than we recognize. But we haven't generally looked for changes in thyroid function, so we really don't know how common that really is. -Dr. West

That type of response with a cavity in the middle of the tumor is classic for what you often see with avastin. There is some debate about whether having a cavitary lesion increases the risk of developing a bleeding complication on avastin, but right now it's not standard practice to discontinue avastin if cavitation develops. It may be that cavitation before treatment starts is really associated with squamous cancer, or in some way that cavitation before chemo/avastin is more worrisome than cavication after treatment starts. We don't really know all of the details yet. -Dr. West

People here have already touched on the main points, but I've written a lot on the subject on the website OncTalk over the last year. The highlights for tarceva are primarily compiled on this list of core concepts for targeted therapies: http://onctalk.com/category/lung-cancer ... e-effects/ You may find some of this information helpful. Good luck, and take care. -Dr. West

You're right that this is a very complex issue, one that is among the most challenging even for experts to discuss. I've participated in many of these discussions and am very aware of the pros and cons of chemo, and I've described several of these issues in detailed posts on my website, OncTalk. Here's a pivotal one if you're interested: http://onctalk.com/2007/09/28/cons-of-a ... -ia-nsclc/ You can find several more in the subject archives for early stage NSCLC there. Good luck and take care. -Dr. West

Thorazine is probably the most commonly used drug to treat hiccups, and another choice is a muscle relaxant called baclofen. Both can be sedating. In addition to it potentially being caused by tumor pressing against the vagus nerve or ticking the diaphragm, several chemo drugs can cause this. -Dr. West

Peachy, Just wanted to add that, like your oncologist, I'll generally use carbo/taxol with avastin, because avastin has been most thoroughly studied with the carbo/taxol chemo doublet. However, if we're not going with avastin (and I can definitely understand your oncologist's concern with coughing up blood, a marker for much higher risk of a life-threatening bleeding complication with avastin), I quite often use carbo/gem as a chemo pair. The most common side effect is decreased blood counts and fatigue, but it's usually quite mild in terms of nausea/vomiting, hair loss, and many other side effects that people might fear from chemo. Most of the typical side effects are things the doctor would need to tell you about ("paper toxicities" of lab abnormalities) rather than things you would feel, and most people prefer side effects they don't feel. The most common issue is that it can drop counts enough that some people can't get treated on as regular a schedule and/or need major dose adjustments because their counts drop too much or too long. Overall, the carbo/gemzar combination has become increasingly popular because it often has a good balance of activity (the common doublets are all remarkably comparable) and side effect profile (quite mild in many people and largely based on blood counts). Good luck with the new regimen. -Dr. West

Sorry to misdirect the thread, but all the talk about Cleveland got me homesick. I grew up there and my family still live on the east side. University Heights and then Beachwood. I wanted to add that I've known Dr. Mekhail for years and he's terrific, both as a nice guy with good judgment and as an expert in the lung cancer world. -Dr. West

For anyone looking for some general background on Pancoast tumors and a current discussion of the latest treatment approaches, I've written some summaries here: http://onctalk.com/2007/10/12/pancoast-tumor-intro/ http://onctalk.com/2007/10/15/pancoast-trimodality-rx/ I hope these posts are helpful to people. -Dr. West

My first instinct was to say that a primary care physician would often be intimidated by the cancer diagnosis and not likely add much to the workup compared with seeing a second oncologist, but the suggestions are right that this could easily be related to thyroid function or some other non-cancer issue. Sometimes oncologists see the world as just "cancer" or "not cancer -- and therefore not a major problem"; a general physician may provide a broader perspective and a pair of fresh eyes to to take in the whole story. Of course, that presumes he'd be interested in seeing someone else. -Dr. West

Peachy, I think you've gotten some great insights here, but if you want to read any more, a few other people have described their experiences with this regimen here: http://onctalk.com/bbPress/topic.php?id=434&replies=15 Good luck. -Dr. West

I don't know of any specific recommendations, except that I would follow the liver function tests (blood tests) particularly closely during treatment (I follow those tests regularly anyway, but I'd be especially vigilant in someone who is high risk for developing problems). Some chemo drugs, such as taxol and taxotere, or some others, are metabolized largely in the liver, so all other things being equal I might avoid those and try to use other agents, such as gemcitabine. I don't know of any real evidence, though, that results are better with some treatments than with others. Overall, the cancer is serious business, so often you just have to deal with it and try to manage problems that may emerge as best you can. -Dr. West -Dr. West

It is true that you can't be "downstaged" after presenting with stage IV disease, but also true that there's a lot of variability in how people do with that. The new staging system will separate stage IV into a group (IVa)now recognized to have better prognosis, with disease limited to the chest (pleural effusion with cancer, other nodules within the lung or involving the pleural lining around the lung), versus a stage IVb population that have more distant disease outside of the chest, recognized to have not as favorable a typical prognosis. However, there's plenty of variability within those groups. Some people with quite advanced disease happen to have a more indolent cancer and/or quite responsive to treatment and can do quite well for years. We're often tempted to do surgery or radiation on a single spot of active cancer if there's no evidence of any other other disease elsewhere. I've done that with a few patients, but unfortunately the cancer has almost always recurred within a few months in other places. So while I'd never say never, as a rule it's quite unlikely that stage IV NSCLC can be effectively treated with local therapy like surgery or radiation to improve survival. -Dr. West