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

I can speak from the perspective of a treating doc. The studies show that alimta has as good a response rate and survival as any drug for previously treated patients (others that have looked favorable are tarceva and taxotere), and actually better than most. I would say that most practicing oncologist I've had significant discussions with feel that alimta is one of the agents with an often very nice balance of mild side effects vs. good activity (at least the best we've been able to do). I have seen a bunch of patients with tumor shrinkage and far more with minimal shrinkage or stable disease that has lasted for several months and been very well tolerated during that time. There are also some descriptions of alimta experiences for lung cancer on my website: http://onctalk.com/bbPress/topic.php?id=444&replies=18 I hope that helps. -Dr. West

I wrote a post at OncTalk about Velcade for lung cancer. It can't speak to what it might or might not do in his trial, but it might provide some useful background: http://onctalk.com/?p=769 I hope that helps. -Dr. West

Jon, Yes, please let me add how sorry I am that you're facing this again. Topotecan is the best studied of the drugs for recurrent SCLC and is very likely an option you'll hear plenty about. I've written about it in several of my posts. Here's a link to a couple of posts I've done on recurrent SCLC at the OncTalk website: http://onctalk.com/?p=467 http://onctalk.com/?p=204 Good luck with treatment. I hope it's effective and not too rough. -Dr. West

Just to clarify: I absolutely stand by what I said. I think it's a great step to run these trials, which will clarify whether there is really something to DCA as a cancer treatment. I am afraid that the story was hyped like crazy based on very scant data, and I recently had the opportunity to speak with another research at the University of Alberta who has been disappointed and dismayed to see how irresponsibly this idea has been promoted. I would love to see DCA or any of several other agents actually show value and be an added effective treatment, but I have recently reviewed research in which other cancer agents like Iressa and Thalidomide have actually harmed people, and I think it's quite possible that DCA could be either completely ineffective or harmful in patients with cancer. The trials should really help us understand it much better. -Dr. West

Congrats, Laurie. Nothing like cancer to put these other medical "speed bumps" into perspective. They become welcome alternatives. And it's good for all of us to remember that not every symptom is actually from the cancer. -Dr. West

It's always reasonable to take a break if a patient wants it. The wrinkle is that SCLC can progress pretty quickly, so often it doesn't allow prolonged breaks before recurring/progressing, particularly if a person has already been treated with several lines of prior treatment. But quality of life is a huge issue here, so I would definitely listen to a patient who needs some time off. In terms of later options, there isn't anything that has any proven value, but some people would try various other chemo drugs that have some activity in lung cancers...it just becomes increasing likely with more and more treatment that it will end up more harmful than helpful. With more time and treatment, the cancer becomes more resistant and our drugs become less effective, while patients tend to get beaten up by both the cancer and all of our treatments. So it ends up a pretty individualized decision about when more treatment just doesn't make sense and is going to clearly be detrimental. But platinum/etoposide and then a drug like topotecan, or sometimes irinotecan, would be the leading drugs people would consider most valuable, and beyond that, it's not clear what the additional treatment provides. We're actively looking for additional effective treatments, but SCLC has been a ridiculously hard nut to crack. Most of our treatments for SCLC have been more or less the same for years and years, because newer treatments just haven't panned out. -Dr. West

This sounds to me like it may be from a neurologic paraneoplastic syndrome. SCLC is a cancer that commonly has something called paraneoplastic syndromes as a complication. This is a situation where the cancer makes proteins that act as hormones, with varied and sometimes complicated effects. SCLC can cause any of several neurologic syndromes from proteins that can attack neurons in the brain, or sometimes receptors that control muscle function. A neurologist would likely be the most helpful way to get this evaluated and managed. Treating the underlying cancer is certainly one important way to approach this, but a neurologist could potentially give further information. I'm not surprised that Emergency Room physicians wouldn't have any idea how to approach these issues, as they are remarkably complicated and really need to be approached by a specialist. -Dr. West

Heather, It's pretty common to have headaches and other symptoms right after coming off of decadron for brain radiation. I usually have my patients go back up to the minimum dose of steroids they need to control the symptoms and then have them taper the steroids more slowly. Steroids are a great treatment for situations like brain swelling, so many times people just can't come off them that quickly, and I just have people take as little as they can get by with, and taper in as timely a way as possible. But some people need to be on steroids for a lot longer than others. It's absolutely worth being in close communication with my doctor. It's not uncommon for me to work for a long time with a patient and have them become sophisticated enough to be able to know exactly what they need and whether they need to increase their decadron (or potentially other steroid) dose. They just keep in good communication with me and my office, and we individualize the plan. -Dr. West

Peachy, I haven't heard of people having a change in what they smell during radiation, but then I haven't gone through it, so others here may say that they experienced it too. There are parts of the brain (temporal lobe) that can be tickled/activated, such as by metastases, to lead to something like hallucinations of smell, like "rotting strawberries" or "burning plastic" strangely enough as a common report. I don't know if you have any cancer involvement in your temporal lobes (you almost certainly wouldn't have been told that level of detail, since it really doesn't change how it's managed vs. other parts of the brain). If the cancer is causing the symptoms, radiation may diminish that sensation over time, or potentially steroids or even anti-seizure medicine might improve that. It's probably worth keeping track of whether that's getting better, worse, or just not changing over time, and keeping in touch with your docs about whether they might suggest anything. These changes in sensation of smell don't tend to be so debilitating, but if it's really bothersome, they may be things to try based on discussions with your medical team. Good luck, Dr. West

Cisplatin and alimta with radiation is an aggressive but certainly appropriate option, especially on a trial. I'm actually participating in a similar trial with this combination, which appears to be as safe as we can expect for a cisplatin doublet with radiation, which has been the type of treatment that has shown the best results we tend to see in this setting. Cisplatin/etoposide has been one of the best studied standards, but it's been a cornerstone forever, and we would welcome an option that uses one of our many effective drugs that have been introduced for lung cancer over the past 5-10 years. However, only a limited subset appear to be safe when given at full dose with radiation. Treating with full dose chemo during radiation allows you to get a boosting effect with the radiation, plus potentially treat microscopic disease outside of the radiation field. Lower dose radiation that is often used instead of full dose cisplatin-based chemo is felt to be less effective in treating the rest of the body. And alimta seems to be one of the drugs that can be given at full dose with radiation, so it's worthy of being studied carefully. Good luck with it. -Dr. West