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March 6th Interactive Chat LOG wtih Dr. West

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drwest[3]: We can start anytime you'd like.

KatieB[5]: ok. enyaw- do you have a question?

enyaw061032[4]: yes - one at a time. I am having radiation 5 days a week for six weeks, and this week and next 3 days in a row of chemo. in my 4th day, and my neck is really red lobster red and a rash on it; and I talked to both radiation and onc and each said it wasn't from their treatment. What can I put on it?

drwest[4]: If it's just four days in that's pretty unusual to get a skin reaction that fast. It's classic to see that several weeks in. I suspect that having that skin reaction just a few days in may be from an unusual interaction of the two. But they're right to presume it's not typical.

KatieB[5]: Judy-OK- Do you have a question?

Judy-OK[4]: Knowing you are an Oncologist and not a radiologist ... I have pain in the area of radiation which was completed in Sept. But PET scan shows stable ... could it be from the radiation??

drwest[4]: Judy, I'd imagine that is related to scarring, tightening of the tissue in the radiation port. It's often like a scar on your skin, tighter than the normal tissue. And that can cause discomfort without being dangerous.

KatieB[6]: Jyoung20- Do you have a question?

Jyoung20[4]: Why is there a warning on the prescription label about taking an antifungal antibiotic with Tarceva? I have currenly been given monocycline for a staph on my scalp..

drwest[4]: well, minocycline is an antibiotic but I don't believe it's an antifungal. It would be one of the many appealing options for skin reactions. I would not imagine any problem with a topical medication. Antifungals, like several other medicines, can affect the liver enzymes involved in tarceva metabolism, changing the effective dose of tarceva, and/or tarceva changing the effective dose of other medicines metabolized by these enzymes. Grapefruit juice also has a major effect on the enzymes.

KatieB[6]: Kathytoma- Do you have a question?

kathytoma[4]: Has been 14 wks since my husbands lobectomy, still so much discomfort, we had all the chemo/radiation before the surgery. Any helpful hints on how or when the discomfort will ease?

drwest[4]: it's pretty variable. There is a condition called "post-thoracotomy syndrome", which is just basically pain after the lung surgery. Some people need pain medicine on a chronic basis, but not most. I'd say that it's still quite possible, probably likely, it will slowly improve, but it may never stop being somewhat painful. Some patients are still on chronic narcotics years later, but if there's no evidence of cancer, most think it was worth it.

KatieB[6]: KathyRae- Do you have a question

KathyRae[4]: After 2 1/2 years of treatment, including carboplatin, gemzar, taxol, and tarceva and now have a great PET scan again. Even though it was clear, the doctor wants me to stay on a "preventative chemo" of taxol and gemzar. I could use a break! I was stage 3b wet - (stage4) with a plueral effusion.

drwest[4]: I wouldn't want to minimize that pain, but just to say that it's more common than many people realize.

kathytoma[4]: Thank you, yes a small price to pay for ned, but we are grateful.

KathyRae[4]: Is this normal to keep taking chemo

drwest[4]: I would say that there's no answer etched in stone, but I don't tend to keep my patients on chemo indefinitely. Your bone marrow only has a certian amount of reserve. I think many oncologists would be fine with, and probably even recommend a break and following you clinically along with scans, leaving more treatment as an option as needed.

KatieB[6]: Liz13- Do you have a question?

Liz13[4]: I've had radiation, and chemo and I'm stable and waiting. I'm also doing very well. We've spoke before. I'm the one who gained 25 lbs after treatment. My esopaguas is much better then before but now my throat is sore up top. It's been that way for a few weeks now with difficulty swallowing. I know that could be a symtom of cancer, but I also suffer from GERD. I also had injections into my vocal cord a few weeka ago and thats about when it started. Any thoughts? Also is this area covered in a CT scan?

drwest[4]: I think that area could be a bit high for a routine CT of the chest. If it's getting worse rather than better, a neck CT might help, but seeing an ear, nose and throat specialist who can take a good direct look may be the most helpful. Otherwise, I think there's a chance it's esophageal candidiasis, a fungal infection we sometimes see in the chemoradiation setting, but one of the docs could do a better job assessing that.

KatieB[6]: MLC- do you have a question?

MLC[4]: Mom will complete 1st line carbo/gemzar in May. What would be the expected 2nd line? Would her Onc immediately start tarceva? (67-NSCLC stage lV)

KathyRae[4]: Liz, I had lost my voice for about a month after taking cisplatin - taking claritin D helped finally

drwest[4]: first, we don't know if she'll progress before then. Many patients progress in less time, and in that case, second line chemo or tarceva would commonly be used. If she gets through all of the planned chemo and is stable, many, and perhaps most oncologists would recommend taking a break and watching closely, with more treatment waiting in the wings to be called on when needed. There's no set protocol for "maintenance" tarceva or rolling right into more chemo after completing first-line treatment.

KatieB[6]: nomclk- Do you have a question?

nomclk[4]: Yes- NSCLC-stage 1a-adenocarcinaoma-lower left obectomy in 2004--no chemo--but have gained about 15 lbs. and cannot seem to lose it--taxing to my breathing to carry around---presently and for past 2yrs;=on plant based diet--andy suggestions to drop this weight--all around my middle--chest area--rib cage area

drwest[4]: I don't have any great recommendations for weight loss except for the basics; do you have any recommendations for me?

KatieB[6]: Sheri- Do you have a question?

Sheri[4]: My Dad’s last chemo was in November for recurrent small cell. He has balance issues but no other problems. Could this be attributed to the cisplatin or camptosar? His last brain MRI was clear.

Sheri[4]: If I can sneak in another Q: Is it possible for SCLC to stabilize? He relapsed in his supraclavical node (biopsied) in August after 18 months of remission. As of January, the node was resolved but he still has a 15mm spot showing up at the original site. He’s 67 diagnosed limited in November 04

drwest[4]: Sheri, I would not think it very likely that the balance is from chemo, but possibly cisplatin caused a problem with the nerves in the inner ear, which are important in balance. It wouldn't be an especially common side effect. I wouldn't imagine it to be related to camptosar. Reassuring to have a negative brain MRI. I'd see a neurologist or Ear/nose/throat specialist, probably best to see a neurologist, because I wouldn't easier connect it to chemo. It's also possible for SCLC to have auto-immune type neurologic problems. I'd say a neurology work-up may be the best bet.

drwest[4]: Just about anything is possible in cancer. We don't often see people follow a slow process and respond well after recurrence, but I saw a patient recently who is four years after his initial Dx of limited SCLC and about 2.5 years out from a relapse. I'm no longer 100% convinced it actually was a relapse, but only because he's done so amazingly well. Anyway, I'd believe anything can happen...

KatieB[6]: Debi- Do you have a question?

KatieB[6]: Judy-OK: Do you have a question?

Judy-OK[4]: I will pass his answer to KathyRae and MLC pretty much answered my next question. P.S. Thanks to both Katie and Dr. West!!!!

KatieB[6]: enyaw061032- Do you have a question?

enyaw061032[4]: Just to clarify my question above, the RADIATION has been 4 days, but the chemo itself has been 4 weeks. Would grapefruit cause this, as I ate a whole grapefruit for breakfast one day. Just that one time

drwest[4]: I can't really see an easy connection.

nomclk[4]: Dr. West- my only recommendation is to continue to come to chat with us all here-and also I have been told that sugar is the worst culprit to cancer patients-as the cells thrive on it--is this true??-Thank you so much for being here.

drwest[4]: There's no real evidence that sugar makes people with cancer do worse. THere's lots of evidence that people losing much weight do worse. I tell my patients to eat a balanced diet, but I don't recommend to avoid all sugar or go on a rigorous diet. I know that's a persistent idea, but I'd like to see the real evidence for it.

KatieB[6]: KathyRae: Do you have a question?

KathyRae[4]: drwest - I have a long lump (3 1/2 inches) beside my port. I shows up negative and feels like a rib bone. Could scar tissue surrounding the port do this?

KathyRae[4]: My doctor has no idea want this is but he is not concerned. Also my pupil in my right eye is staying small. Doc says it is because of a nerve - Horner syndrome. Will this ever go away

drwest[4]: Yes, I think it's quite possible that there could be some scar tissue around the port.

drwest[4]: very possible that nerve damage won't go away, if it's been present for a long time.

KatieB[6]: CHICAGO, Illinois (AP) -- A new study suggests that screening smokers and former smokers for lung cancer doesn't save lives or prevent advanced disease and may lead to unneeded and harmful treatment. **Have you heard of any new early detection methods that are being investigated? Sure wish they'd find something for early detection..

drwest[4]: People are looking into sputum cell detection. The screening stuff is definitely still an open question. The folks who ran that trial at Mayo are good, smart docs, and it's a legitimate question to consider along with the conclusions from the other study. It's not a simple story...

KatieB[6]: thanks!

KatieB[6]: Liz13: Do you have a question?

Liz13[4]: I've was diagnosed with esophageal candidiasis in January. That was what I think caused me to vomit for 9 weeks and lose all the weight. My GI found it and gave me anti fungus meds for 14 days. Haven't vomited since. I have a re exam scheduled for for April 6th with the camera. Should I try to move it up sooner?

drwest[4]: If you're still having throat/swallowing symptoms, I'd probably talk with the doc about that/

KatieB[6]: MLC: Do you have a question?

MLC[4]: Is Endostatin/Endostar an option here in US?

drwest[4]: Endostatin's been studied but hasn't shown any especially promising results. Avastin is another anti-angiogenic drug that so far has shown proven survival benefits in lung and colon cancer and shown good suggestions of benefit in breast cancer as well. There are many other anti-angiogenic drugs that are looking promising. I wouldn't be particularly focused on endostatin with other good options with the same mechanism available.

KatieB[6]: nomclk: Do you have a question?

KatieB[6]: RandyW: Do you have a question?

RandyW[4]: thoughts on Nutrigenomics?

drwest[4]: To be honest, I don't think I understand nutrogenomics.

RandyW[4]: study of Nutrition and genome system relatively new and upand coming thanks

drwest[4]: Seriously, I do think that in the enxt few years we're going to be doing a much etter job of personalizing cancer treatments based on lung cancer genes. We may do similar things with nutrition, but oncologists won't be leading that effort.

KatieB[6]: Sheri: Do you have a question?

Sheri[4]: What are your thoughts on dichloroacetate (DCA)? Oh, and can buy you dinner at the cafeteria?

drwest[4]: Sorry, what I was saying is that DCA is interesting, a promising idea and has some encouraging results, but they're way, way early results. We've cured lots of mice of cancer, and killed lots of tumor cells in test tubes, but it's much harder to get the treatments to work in real people with living cancers. I think DCA is one of many things worth studying, but I don't think the scant evidence with it merits leapfrogging all of the other promising approaches. It somehow picked up huge buzz, but it's just one of many interesting drugs worth testing.

drwest[4]: And I'm always open to diner.

drwest[4]: Er, dinner.

drwest[4]: I'll also say that I did a post on DCA on OncTalk, if anyone wants to learn more.

KatieB[6]: http://www.onctalk.com

KatieB[6]: ellakc2: Do you have a question?

ellakc2[4]: I had an upper right lobect. 3 yrs ago the scar is still tender , how long should that last

drwest[4]: if it's been three years, it's probably going to stay pretty much like that. I'd have my patients on chronic, long-acting pain medications as needed.

ellakc2[4]: what about acuputure?(sp?)

drwest[4]: not my expertise, but there have been some studies suggesting anti-nausea benefits, and I personally suspect that there's much more to learn. There's some concern about infection if people have low blood counts, or may have bleeding with low platelets, but outside of that, I suspect there may be benefits that oncology/western medicine may not yet appreciate and understand, or just have no effect at worst.

KatieB[6]: Judy-OK: Do you have a question?

nomclk[4]: dr. West- are you familiar with Essiac herbs--for tea--and if so - do you feel they may be helpful in control of cancer?

drwest[4]: Sorry, I had a glitch. The last question I saw was on essiac. I'm back. I don't know of much data either way. I'm impressed with the naturopathy pages on the Memorial Sloan Kettering and MD Anderson websites and would look there. I don't have much direct knowledge or know of data either way about it.

drwest[4]: here's the page for MSKCC: http://www.mskcc.org/mskcc/html/11570.cfm

drwest[4]: here's the page from MDACC: http://www.mdanderson.org/departments/C ... 508B603A14

nomclk[5]: Oh thank you so much - !!

KatieB[6]: JYoung20: Do you have a question?

KatieB[6]: Kasey: Do you have a question?

Kasey[4]: My husband, Fred, was dx with nodules - 2 in lobes in rt. lung and one in the left. He has had the normal protocol of scans - 3 mo, 6, etc. Last showed pneumonia. His doc now has upped the LAST scan to April. Then he said no more. Would you recommend more?

Kasey[4]: All nodules are 2 and 3 mm

drwest[5]: the protocol I know of is evaluating nodules with scans every three months for up to two years, but if there's improvement, I think it makes sense to decrease the vigilance. If stable, I would follow my patients for longer.

Kasey[5]: Sorry dx in July '04

Kasey[5]: Longer than 2 years?

drwest[5]: If no growth over 2-3 years, that's pretty reassuring...

drwest[5]: I don't think there's any standard recommendations for follow-up more than 2 years if nodules are stable for that long.

KatieB[7]: KathyRae: Do you have a question?

KathyRae[5]: drwest - With stage 4 cancer, how do you ever know if you are in remission? My first doctor told me remission wasn't possible. I feel great, and other than tiredness and problems relating to chemo, I have no symptoms. Not even shortness of breath! I was wondering also if Avastin would be available to me after taking Tarceva for a year and it not working anymore?


drwest[5]: I don't use the term remission, but I know some oncs do. I think of remission as a complete response to a blood-based tumor like leukemia or lymphoma. But we occasionally (but rarely) see a complete response in lung cancer. Perhaps 1-3% of the time, so not common, and I don't expect to see it. We're very happy to see clear shrinkage, the tumor

drwest[5]: In terms of the avastin question, it's been combined with tarceva and appears to be generally safe in that combo, but still with some small risk of serious or even fatal bleeding (low single-digits range). Still not known whether it would add value in the situation of slow progression after response to tarceva. Some insurance companies may balk at paying, as well.

KathyRae[5]: drwest - My last PET scan showed no tumors! I know I'm very lucky.

drwest[5]: Congratulations, Kathy.

KatieB[7]: Liz13: Do you have a question?

KatieB[7]: MLC: Do you have a question?

MLC[5]: Avastin is not an option with Mom's squamous cell CA. Are any of the other anti-angiogenics an option for her?

drwest[5]: The jury's still out on whether other antiangiogenics have a similar bleeding risk with squamous cancers. THey haven't been studied as extensively as avastin in lung cancer. My read of the available evidence is that other anti-angiogenic drugs also have a very real risk of bleeding, so it's probably a class effect, at least from what I can see. Trials are testing this, but I'd personally be cautious.

KatieB[7]: nomclk: Do you have a question?

KatieB[7]: nonni: Do you have a question?

nonni[5]: Dr West...my stage LC was 1 a ...I see my surgeon with a chest exray every 6 months...and the onc every year with a ct/scan and blood work...do you think that is sufficient...2 and a half yrs from surgery

drwest[5]: We don't have any ironclad standards. I do think that's very reasonable. I personally do CT scans every 4 months in the first year, then every 6 months until4 years, then yearly. The risk of recurrence has clearly already gone down a lot after 2.5 years, and your prognosis started out very favorable. If anything, I'm over-doing the scans, as the surgeon I work with is also a national lung cancer experts and does chest x-rays over CT scans very commonly. So no best answer.

drwest[5]: I don't worry much about radiation dose from CTs in people being followed for active cancer, but if you're going to be following someone likely for years and years, we don't want to do more CTs and deliver more long-term radiation than needed. We also don't want to under-study someone and let things go too long.

KatieB[7]: Roger C: Do you have a question?

nonni[5]: Thank you Dr West.....Thanks Katie


KatieB[7]: Sheri: Do you have a question?

Sheri[5]: I do Katie, thank you. Dr. West, can biopsies be wrong and/or jaded by patient histology? Where do you want me to place your dinner order and what would you like? Here I am with two questions again...

KatieB[7]: anarchist

KatieB[7]: lol

drwest[5]: Sheri, I'm actually covered for dinner...my kids are still hoping to see me at home, but THANKS!

drwest[5]: It's possible that pathology can have a mistake, as anybody can make an error, but the pathology is considered the "gold standard" for clarifying what's going on. But some cases are tough enough that they require input from several good pathologists and even review at other centers.

Sheri[5]: I actually asked three....Thanks for being here, not only were you informative but you made me laugh.

KatieB[7]: ellakc2: Do you have a question?

ellakc2[5]: Dr. West after 5 yrs out have you seen lc return

drwest[5]: After 4 years, the risk is greater of a new cancer than the old one returning. The real reason we continue scans beyond 4 years is that someone who developed a LC remains at risk for another down the line. The only time when I would not consider someone "out of the woods" would be BAC (bronchioloalveolar lung cancer), because it can be so slow growing it may return many years later. On the other hand, if it comes back after 8 years, it's probably a very slow-moving cancer that may not be a threat to survival.

KatieB[7]: We have about 10 minutes left folks...

RandyW[5]: do you see any new treatments that stand out from the rest?

drwest[5]: Randy, I think several could end up being useful LC treatments in the next few years. Sutent, Nexavar, another anti-angiogenic called AZD2171, the combined antiangiogenic and EGFR inhibitor Zactima, all could find a useful place. Others also; I have always been pretty skeptical about vaccines but think the Stimuvax and another vaccine (against the protein MAGE) are worth a good look.

RandyW[5]: tnax for your time Dr West i AM new treatment Moderator

enyaw061032[5]: Two questions, the first one most important to me. Is it common for someone to go from a nsclc stage la and all scans, etc be negative for 2-13/4 years, and then WHAM, a whole new ballgame with not a recurrence but with a totally different new lung cancer on same right lung, with mets to bone on T9? 2nd part: what could cause neck redness, dryness so bad it is flaky and pulling when I turn my head, and shriveled up ? As stated before, I have had 4 wks chemo and 4 treatments of radiation,

drwest[5]: enyaw061032, I would believe that scenario is possible. People can present with metastatic lung cancer as their initial presentation all the time. I'm sorry if that's how it happened, but I'd never put anything past LC. As for your 2nd Q, what was the chemo? gemzar is very hard to combine with chemo and can lead to major problems if given at the same time. Other drugs may need to have signifciant dose reductions with concurrent radiation.

ellakc2[5]: I have large cell lc (subdivision clear cell) there is not much info. on it ,do you know if it's rare?

drwest[5]: Sorry, I don't have any particular info on clear cell. I think it is pretty rare, and I would treat it in general like other NSCLC subtypes. Sorry, but I can't recall the last time I've seen that.

KatieB[7]: Muriel: Do you have a question ?

KatieB[7]: Jyoung20: Do you have a question?

Muriel[5]: No, but thanks

KatieB[7]: Kasey: Do you have a question?

Kasey[5]: Due to pain from extensive anterior surgery I have muscular and joint pain pllus back pain. Are you familiar at all with leopard's bane - 'arnica' montana? Recommended by a friend.

drwest[5]: not familiar at all with leopard's bane. Please let people know if it's helpful.

enyaw061032[5]: Dr West, I forgot to say the lst nsclc was bronchoalveolar, seccond one 2-3/4 yrs later (now) is SMALL CELL

drwest[5]: Enya, yes, those are probably completely unrelated. THat's certainly a leading combination that would do just what happened.

KatieB[7]: We have about 4 minutes left folks...

nomclk[5]: thank you so much Dr. West-until next time......

KatieB[7]: Kathyrae: Do you have a question?

KathyRae[5]: Thank you for being soooo helpful. I was wondering why my doctor only orders PET scans for me, never CT scans. Every 6 months he orders MRI's of the brain. I had only one biopsy in the hospital 2 1/2 years ago with my plueral effusion. The hospital lost my x-rays, and for a day lost records of my lab results. It has always made me nervous about a missed diagnosis. When I questioned my doc he said he saw my cells under the microscope personally. I hope I can trust him, but I have changed docs. Should I request a new path report after 3 years?

drwest[5]: Kathy, I think it's reasonable. Are you asking for a copy of the report from years ago, or for something to be re-biopsied. Was I right in understanding you have no evidence of disease now? If so, good for you. Strange things can happen, and we've all had patients who don't follow the rules (that's good, if the rule doesn't look very good).

enyaw061032[5]: Thanks, Dr. West, and thanks, Katie.

KatieB[7]: thank you enya!

KatieB[7]: Franca, do you have a question for Dr. West?

KatieB[7]: OK Folks, thank you all for participating tonight and a BIG thank you to Dr. West who is just the BEST!! Thank you again so much for your time tonight!!

nomclk[5]: thank you Katie

drwest[5]: thanks everyone for sticking around and for your attention and good questions. keep me on my toes.

Kasey[5]: Thank you, Dr. West. You are a true 'good' guy!

MLC[5]: Thanks katie and Dr. West!!!!

Kasey[5]: Thanks to you too, Katie!

RandyW[5]: thanks again!!!

Sheri[5]: Thanks Dr. West!

KatieB[7]: Feel free to stick around for General Chat moderated by Randy W.

RandyW[5]: hi there

KatieB[7]: I will have this interactive chat transcribed and put in the "Ask the Experts" Forum

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