DrWest

Although it may be a bit of a moot point because your dad's probably going to not get the same chemo again, I wanted to give an oncologist's perspective. In general, they're pretty comparable in activity, although several studies show a minor advantage for cisplatin in lung cancer. It probably doesn't amount to much of a meaningful difference for stage IV NSCLC, but for stage I - III, I often recommend cisplatin for patients who can tolerate it, because it's probably a shade more active, and that difference counts for more in earlier stage disease. However, if we favor cisplatin, it's not because it's easier to tolerate, because it generally isn't. It can cause kidney damage, worse nausea/vomiting, hearing loss, and neuropathy (damage to the nerves, typically the longest in the body, so affecting the fingers and toes first). Cisplatin does not tend to cause as much of a drop in blood counts as carboplatin, though. Otherwise, carboplatin can cause the cisplatin side effects, but generally considerably less of all of those except for blood counts dropping. It is possible to minimize some of the side effects of cisplatin by splitting it over 2 or more days, rather than one big slug, which makes it very nausea-inducing and hard on the kidneys. I give it over two consecutive days, or split over two weeks with gemcitabine if some is getting gemcitabine IV two weeks out of three, for instance. Much less of a challenge. Both of these drugs are usually paired with another drug like taxol or taxotere, or gemcitabine or navelbine, and the other drugs can contribute to side effects as well.

The vast majority of the research on giving chemo after surgery is in stage IB to IIIA NSCLC. A "meta-analysis" that pooled data from several clinical trials of post-op chemo for various stages concluded that chemo for stage IA was detrimental. Although there are some controversies about who should be recommended to receive post-operative chemo, stage IA has little or no controversy, because just about every expert as well as regular oncologist agrees that, at best, there is little or no evidence for it, and it may be harmful. I summarize the evidence on post-operative chemo on my website. This includes very little on stage IA, because this stage is felt to have too good a prognosis to offer a treatment with a real toxicity risk that could be greater than the minimal or no added benefit expected. The relevant posts are here: http://onctalk.com/2006/10/28/chemo-aft ... cer-nsclc/ http://onctalk.com/2006/10/30/what-are- ... motherapy/ In short, no experts or guidelines for best treatment make a recommendation to give post-operative chemo to stage IA. I hope that helps.

It's most typical to do scans every 2-3 cycles to check if things are improving, stable, or progressing. If patients have new symptoms or are just having a hard time with side effects from treatment, that would lean me toward doing a scan earlier rather than later, but repeating scans every cycle would be quite unusual. Insurance companies tend to question if you get scans less than a month apart, except if you document that it's to assess for change in someone with new, concerning symptoms. I hope her next scan looks favorable.

This primarily just reiterates the good info already provided, but I'll give input as an oncologist. Radiation isn't generally done to asymptomatic or minimally painful bone mets unless there's a significant fracture risk. Radiopharmaceuticals are very rarely used for lung cancer. Primarily for prostate cancer, where patients often develop very diffuse bone metastases over a very long time. Zometa infusions can decrease the risk of future skeletal complications, like subsequent fractures, need for radiation, or increased pain medication, in folks who have metastases to bone. And doxycycline, although perhaps being studied in some clinical trials, is definitely not routinely used in bone metastases at this point.

Welthy is right. That link must be from a google ad which I don't control. There's an automatic algorithm that just looks at the words on my page and selects ads on a similar theme. I'm glad if people find such information useful, but please don't presume that I'm advocating any of these. These ads are placed automatically. If I find some that I specifically object to, I can specify for them to be blocked, but I'm definitely not selecting which google ads go where, and I can't vouch for any of the information on the links.

Avastin has no documented activity as a single agent and is generally given with another agent like standard chemo or tarceva. I would say that many patients don't have an especially hard time with alimta, although a few do. It was approved by the FDA because it had the same degree of activity in previously treated lung cancer patients as taxotere (docetaxel) but less toxicity. Tarceva is often pretty mild in terms of side effects but works best in patients with little or no smoking history, somewhat less well in folks with a more significant smoking history. We don't know much about which patients respond well or less well to standard chemo, except that patients who responded well to first-line chemo are more likely to do well with their next chemo. I'd be more inclined to recommend tarceva next for someone who didn't respond as well to chemo the first time around.

I think most of the highlights have already been well covered in the comments, but I've written a summary of the recent history and current ideas on best management of ED-SCLC on my website. It's available here: http://onctalk.com/2006/11/26/old-and-n ... sive-sclc/ There are also several newly written articles on other aspects of SCLC elsewhere on the website.

Ernie, I agree with your point about never-smokers and remote prior smokers. The issue about never-smokers has been that they are a group that pretty consistently shows a major benefit from Tarceva, while results in current or prior smokers tend to be less consistent. However, it has been observed that people who quit smoking decades ago, especially people who didn't smoke more than 10 or 15 "pack-years" in total (the product of number of packs per day smoked x number of years smoking) often have the EGFR mutation and can do as well as never-smokers on Tarceva. So there are people who happened to smoke a long time ago but really developed the "never-smoker" kind of lung cancer, probably just by random bad luck. If anyone is interested, in the post attached with the link that follows, there is a slide/figure that includes a table showing increasing likelihood of having the EGFR mutation as more time elapses since quitting smoking: http://onctalk.com/2006/11/22/never-smo ... treatment/ And yes, many of us are seeing lots of never-smokers, seemingly in growing numbers, and especially women. In the northwest, where I practice, about 25-30% of my lung cancer practice is never-smokers, disproportionately Asian women, for reasons we don't understand.

I certainly don't know the details of the situation, but one of the reasons that surveillance after treatment remains controversial is that there isn't always a clear benefit to finding recurrence early vs. later. Earlier scans might very well have shown the same problem, but he might have found out about it earlier, which wouldn't necessarily be a major benefit. I tend to do scans on the more frequent side, but it's debatable how beneficial that is. I don't know if it will help to think in this way, but spread of cancer from colon to lungs wouldn't generally be much better to find earlier. Just as you can't be just a little pregnant, most of the time having any metastases is an all or none proposition, with rare exceptions. Happy Thanksgiving. -Jack

To respond to the question of bone mets from BAC, pure BAC, which is far less common than the mix of adeno with BAC features, can't invade tissues and just grows in the lungs, like moss, or a coating of paint over the thin lining that gas moves through in the lungs. Covering that lining means that oxygen can't get through, and the lung area involved doesn't work well. Regular adenocarcinoma is invasive and can spread to bones, brain, liver, and other places. If a cancer was said to be BAC but had spread outside of the lungs, I would conclude that it had to be a mixture of adenocarcinoma and the non-invasive BAC form. That mix accounts for something like 15-20% of all NSCLC. Importantly, the trials we're running for BAC allow patients not only with pure BAC but with the adeno+BAC mix to participate, and the trials thus far show that the ones with the mix are just as likely or more likely to do with with drugs like Iressa and Tarceva than patients with pure BAC. If you want some pictures or more detail, I have a summary of the spectrum from pure BAC to invasive adenocarcinoma here: http://onctalk.com/2006/10/11/defining- ... ne-end-of/ As for the question of irreversible inhibitors, I'm doing a trial with one of them (Wyeth's drug HKI-272) at my own institution, but it's too early to say whether they add anything beyond what tarceva can do (and I'm bound by a confidentiality agreement not to divulge inside information about the trial before it's publically available). Some test tube studies suggest they may be helpful in some folks, like those who previously responded to Iressa or Tarceva and then had the cancer progress, but we're still gathering information from the trials in real people.

I have prescribed a lot of tarceva for my patients and have generally had my patients use cleocin T gel and hydrocortisone cream for less severe reactions, and oral antibiotics such as minocycline and/or steroids (generally steroids for closed spots and antibiotics for whiteheads and open lesions). I lecture about tarceva, and the word I had heard from most of the people who work a lot with Tarceva is to NOT use accutane. I think part of this is based on concern for side effects, as Peggy mentioned. Part is that the rash from tarceva isn't quite the same as acne, from what I hear from the few "tarceva rash experts". One of the other tips that I've heard works very well is Elidel cream, which I haven't had the need to use yet on one of my patients, but the few docs I've spoken to about it have noted very good results. And Elidel cream is now one of the recommended approaches in the guidelines that have been presented in lectures for oncologists, and in published articles about tarceva rash management.

Radiation is useful for lung cancer in certain circumstances, but not as often when there are multiple spots from cancer. Radiation and surgery are both more useful when there is a single tumor, possibly with some nearby lymph nodes, but rarely used when there are metastatic additional spots elsewhere in the lungs or in other parts of the body. Radiation can also be useful to treat pain (such as painful bone lesions from cancer) or shrink a large tumor area in a hurry (if the cancer is big and pressing on important blood vessels or airways in the chest). But chemotherapy (sometimes also targeted whole body therapy, like tarceva or avastin) is the main type of treatment used if there are multiple areas to treat, because chemo goes through the bloodstream to treat pretty much all throughout the body at once.

Although I specialize in lung cancer in general, my greatest particular interests are BAC and never-smokers with lung cancer. I have posted a few general topics on BAC on my blog thus far, available through this link: http://onctalk.com/category/lung-cancer ... ancer/bac/ I am planning to add a good bit of additional information about BAC and also never-smokers with lung cancer on this site over the next several weeks and months. I hope this information is helpful. -Jack

My name is Dr. Jack West and I'm an oncologist in Seattle with a particular interest and expertise in lung cancer. I lead several clinical trials and speak to audiences of patients and, more commonly, other medical professionals, about the latest treatments for lung cancer. Although I haven't been in this discussion setting, I've participated on several ACOR lung cancer lists over the last several months, trying to add answers to questions from an oncology professional with a major interest in lung cancer. I just started a lung cancer blog, which I intend to regularly update with new information about the current state of the art, new agents, interesting clinical trials, and controversial issues in the field. I want to welcome people to check out the site, which includes archives of the subjects I've done, and the search function will be improved (as soon as Google recognizes the site, which will be when people visit and link to it, so Google sees it's not a junk/spam site). Anyway, come check it out a the following web address: http://www.onctalk.com/post/ I would very much welcome your suggestions. I want to provide information that patients and families want and need, information that isn't already available elsewhere. Thanks, Jack West