therapy after surgery

[hope16]

hello all

its been just three weeks since my husband diagnosed with lung cancer adenocarcinoma.

and two weeks since he got operated. By God's grace , his pathology reports are good. He got his lower lobe of right lung removed and has clear margins and negative for lymph nodes.

I am yet to come to the terms with this. My husband is just 35 years old, non smoker and has always been fit. He was staged at 3A and now it is restaged to 1b.

my question is: Should we go for chemeotherapy or targeted therapy as I am getting two different opinions from different oncologists. Please guide me. How does his prognosis looks like? Will he be cured?

[Laurel]

I had surgery removing top right lobe and 13 lymph nodes. I was told at M D Anderson that I was cancer free. My initial staging was I b. After surgery, it was III b. Since lung cancer can be persistent, 4 rounds of chemotherapy were recommended ....which I just completed....and 6 weeks of daily radiation. It is still difficult to wrap my head around "cancer free" and this follow up treatment, but it was recommended by both M D Anderson and my local oncologist.

[LexieCat]

I was staged at Ib, and my doctors (surgeon and oncologist) said with that stage, it's almost a coin toss whether chemo will do any good.  With Stage Ia, chemo has actually been shown to do more harm than good.  With Stage II or higher, chemo is always recommended.  My doctors went over the pros/cons with me and I opted to have no chemo.  According to them, chemo adds maybe a five percent better chance at overall survival.  That's looking at a huge range of cases and statistical probabilities.  There's a good chance that the surgery alone would be sufficient.

It's been over a year and no signs of cancer.  I'm very happy with my choice.  The doctors examine my scans every six months, so if something DOES happen, they will be on top of it and we can do chemo (or targeted therapy etc.) then.  I'm confident in my doctors and they were both very supportive of no chemo--my surgeon actually recommended against chemo, and my oncologist was neutral but was just fine with my decision.

[hope16]

thanks a lot

he is staged 1b after surgery. And because of the size of tumour which was5-6cm doctor recommends more therapy. Not sure whether to go for targeted or for chemeotherapy.

[hope16]

1 hour ago, Laurel said:

I had surgery removing top right lobe and 13 lymph nodes. I was told at M D Anderson that I was cancer free. My initial staging was I b. After surgery, it was III b. Since lung cancer can be persistent, 4 rounds of chemotherapy were recommended ....which I just completed....and 6 weeks of daily radiation. It is still difficult to wrap my head around "cancer free" and this follow up treatment, but it was recommended by both M D Anderson and my local oncologist.

I am wondering if your lymph nodes were negative then why did you have to have radiation?

[Laurel]

Of the 13 lymph nodes, 4 had cancer and were removed. At first, M D Anderson radiologist said there was nothing to radiate....but then recanted and said they need to radiate area of lympth nodes removed and near where top lobe removed.

[LexieCat]

It's possible the considerations are different when the Ib is based on tumor size.  Mine was relatively small, but staged as a "b" due to possible pleural invasion (surgeon didn't believe there was any but pathologist thought differently, and the pathologist carries the day).  

Did the oncologist specify the exact drugs they were considering, either for chemo or for the targeted therapy?  What was the result of the testing for mutations--which mutation did they find?  If you can tell us about that, then folks who have experience with the same treatments can talk about their experience.

[Tom Galli]

Hope16,

Let me see if I can help you.  Your question is with a staging of IB and a complete surgical resection of the tumor, should one have post surgical targeted therapy or chemotherapy.  First, understand that targeted therapy is a form of chemotherapy.  Here is some information on the different forms of targeted therapy.  Both targeted therapy and chemotherapy attack cancer cells throughout the body but they attack in different ways.  So, there are, in effect, three options for your consideration: (i) no post surgical treatment; (ii) targeted therapy;  or (iii) chemotherapy.  There are actually more treatment options but to avoid complexity, let's consider your choices to be more treatment or no more treatment.

Why is post surgical chemotherapy a suggested treatment course?  Lung cancer is very persistent.  Surgical complications precluded me from having post surgical chemotherapy after my right lung was removed.  When I recovered from surgery, I was diagnosed with tumors in my left lung.  Likely, there were cancer cells throughout my blood stream and some decided to settle in my lung.  Chemotherapy does a good job at eliminating cancer at the cellular level.  It is less effective when attacking cancer that has formed a mass or tumor.  So post surgical chemotherapy combines the strength and precision of surgical resection with body-wide elimination of future metastasis (hopefully). 

Here is a essay about lung cancer persistence. The referenced National Cancer Institute study suggests a 1 in 3 chance of a lung cancer recurrence after successful treatment at stage IB.  Either post surgical targeted therapy or chemotherapy reduces that chance of reoccurrence.  

To your second questions: what is your husband's prognosis? My answer here also addresses your cure question.  We don't use the word cure in the lung cancer community because of the high likelihood of recurrence, and on recurrence, mutation to a treatment resistant form.  We use the term no evidence of disease or NED.  I have survived nearly 15 years after diagnosis of Stage IIIB non small cell, squamous cell, lung cancer.  I had three lines of treatment to address the metastasis to my remaining lung.  My doctor believed my cancer became resistant to chemotherapy and thankfully a new form of precision radiation emerged out of research just in time to save my life.  I had a little over three years of constant treatment to achieve NED. Had I had post surgical chemotherapy, I might not have had to endure the three years of further treatment.

No one can answer a life prognosis question with precision. Your husband is young, likely in good health, and has received the most effective treatment for early discovered lung cancer -- surgery.  Relying on the National Cancer Institute data without post surgical chemotherapy, he has a 33% chance of recurrence.  With post surgical chemotherapy his percentage, statistically, is less than 33%.  How much less I would not know. 

Welcome here.  

Stay the course.

Tom

[BridgetO]

'Hi Hope, You've received some really good answers from other forum members. With stage 1B, there's no set answer to whether further treatment is needed. My lung cancer was 1a so I didn't need any treatment after my lower right lobe was removed.  I was 71 and in good health when I had surgery in November 2016. I recovered quickly. I'm doing well.  I have CT scans every 6 months and I'm NED. There is every reason to think your husband, at age 35, will do at least as well.

Bridget O

[Robert Macaulay]

My first cancer 2A in my throat required no further treatment after my surgery.

Bob

[hope16]

9 hours ago, Tom Galli said:

Hope16,

Let me see if I can help you.  Your question is with a staging of IB and a complete surgical resection of the tumor, should one have post surgical targeted therapy or chemotherapy.  First, understand that targeted therapy is a form of chemotherapy.  Here is some information on the different forms of targeted therapy.  Both targeted therapy and chemotherapy attack cancer cells throughout the body but they attack in different ways.  So, there are, in effect, three options for your consideration: (i) no post surgical treatment; (ii) targeted therapy;  or (iii) chemotherapy.  There are actually more treatment options but to avoid complexity, let's consider your choices to be more treatment or no more treatment.

Why is post surgical chemotherapy a suggested treatment course?  Lung cancer is very persistent.  Surgical complications precluded me from having post surgical chemotherapy after my right lung was removed.  When I recovered from surgery, I was diagnosed with tumors in my left lung.  Likely, there were cancer cells throughout my blood stream and some decided to settle in my lung.  Chemotherapy does a good job at eliminating cancer at the cellular level.  It is less effective when attacking cancer that has formed a mass or tumor.  So post surgical chemotherapy combines the strength and precision of surgical resection with body-wide elimination of future metastasis (hopefully). 

Here is a essay about lung cancer persistence. The referenced National Cancer Institute study suggests a 1 in 3 chance of a lung cancer recurrence after successful treatment at stage IB.  Either post surgical targeted therapy or chemotherapy reduces that chance of reoccurrence.  

To your second questions: what is your husband's prognosis? My answer here also addresses your cure question.  We don't use the word cure in the lung cancer community because of the high likelihood of recurrence, and on recurrence, mutation to a treatment resistant form.  We use the term no evidence of disease or NED.  I have survived nearly 15 years after diagnosis of Stage IIIB non small cell, squamous cell, lung cancer.  I had three lines of treatment to address the metastasis to my remaining lung.  My doctor believed my cancer became resistant to chemotherapy and thankfully a new form of precision radiation emerged out of research just in time to save my life.  I had a little over three years of constant treatment to achieve NED. Had I had post surgical chemotherapy, I might not have had to endure the three years of further treatment.

No one can answer a life prognosis question with precision. Your husband is young, likely in good health, and has received the most effective treatment for early discovered lung cancer -- surgery.  Relying on the National Cancer Institute data without post surgical chemotherapy, he has a 33% chance of recurrence.  With post surgical chemotherapy his percentage, statistically, is less than 33%.  How much less I would not know. 

Welcome here.  

Stay the course.

Tom

thank you Tom for your precise answer. I will discuss it all in the upcoming meet with the onco .

[hope16]

7 hours ago, BridgetO said:

'Hi Hope, You've received some really good answers from other forum members. With stage 1B, there's no set answer to whether further treatment is needed. My lung cancer was 1a so I didn't need any treatment after my lower right lobe was removed.  I was 71 and in good health when I had surgery in November 2016. I recovered quickly. I'm doing well.  I have CT scans every 6 months and I'm NED. There is every reason to think your husband, at age 35, will do at least as well.

Bridget O

my best wishes with you

 

 

[hope16]

4 hours ago, Robert Macaulay said:

My first cancer 2A in my throat required no further treatment after my surgery.

Bob

Thats really a great news....my best wishes

[hope16]

hey Tom

can I deduce from what you wrote that there are still handful of people whose cancer never came back? Want to hang on to hope.

[Tom Galli]

Hope16,

The way I interpret the National Cancer Institute Data a majority of people who have a surgical resection at stage IA and IB never have a recurrence.  This study published in 2015 states that about 66 in 100 people with lung cancer at stage IA and IB who had a successful surgical removal did not experience a recurrence.  Sixty-six percent is a big number and it illustrates that surgery is the most effective therapy when cancer is discovered early.  Your husband's cancer was discovered early and apparently removed completely.  So way more than a handful go on to live without a recurrence; a significant majority go on to live without a recurrence.  There is a lot more than hope in your husband's situation.  There is statistical validation of life without lung cancer.

But, 33-percent experience a recurrence (33 people out of 100) and when lung cancer recurs, it often mutates becoming more difficult to arrest with chemotherapy.  I was one of the 33% unlucky enough to experience a recurrence after surgery and I did not have post surgical chemotherapy.  I can't know if post surgical chemotherapy would have prohibited my recurrence, but it is a standard of care for most diagnosed with stage IB through IIIA after surgery.  I conclude therefore it does enhance survival probability.  Here is the study I'm discussing.  Print a copy and discuss it with his doctors.

Stay the course.

Tom

[LexieCat]

Tom, that link doesn't work.  When I click it, I get an error message: "Your session has timed out. Please go back to the article page and click the PDF link again."

Can you try to re-post?

[LexieCat]

FYI, the link now works.  Thanks, Tom!

[hope16]

12 hours ago, Tom Galli said:

Hope16,

The way I interpret the National Cancer Institute Data a majority of people who have a surgical resection at stage IA and IB never have a recurrence.  This study published in 2015 states that about 66 in 100 people with lung cancer at stage IA and IB who had a successful surgical removal did not experience a recurrence.  Sixty-six percent is a big number and it illustrates that surgery is the most effective therapy when cancer is discovered early.  Your husband's cancer was discovered early and apparently removed completely.  So way more than a handful go on to live without a recurrence; a significant majority go on to live without a recurrence.  There is a lot more than hope in your husband's situation.  There is statistical validation of life without lung cancer.

But, 33-percent experience a recurrence (33 people out of 100) and when lung cancer recurs, it often mutates becoming more difficult to arrest with chemotherapy.  I was one of the 33% unlucky enough to experience a recurrence after surgery and I did not have post surgical chemotherapy.  I can't know if post surgical chemotherapy would have prohibited my recurrence, but it is a standard of care for most diagnosed with stage IB through IIIA after surgery.  I conclude therefore it does enhance survival probability.  Here is the study I'm discussing.  Print a copy and discuss it with his doctors.

Stay the course.

Tom

I am Feeling positive after coming here and discussing my doubts with you guys. My oncologist is very optimistic guy who even went on to say that he is cured. I believe in optimism and faith. I have both now and I want my husband to have the same. Thanks a lot.

[hope16]

so we met with two oncologists and both of them want to proceed with chemotherapy four cycles every three weeks . Since my husband I egfr positive, they are tempted to continue with the drug once the chemeotherapy gets over. But this decision will be made only after the chemeotherapy is over. My question is does itseem like overtreatment? How much toxicity can one live with? Please enlighten me here since the decision has to be made by us.

[Tom Galli]

hope16,

Four cycles of chemotherapy in twelve treatment weeks is pretty normal for post surgical chemotherapy. After this therapy, a post treatment scan will be administered and the results will determine if more treatment is warranted.  Your husband's tumor displays EGFR positive and that is a good thing because new tyrosine kinase inhibitor (TKI) drugs (erlotinib, gefitinib, afatinib and osimertinib) can treat his cancer should it return after post surgical chemotherapy.  

This approach does not seem like over-treatment.  It is a standard of care to administer post surgical chemotherapy for Stage IB resections and having TKI drugs in reserve is a very good thing because it is a different attack approach to bolster against a mutation recurrence. I wouldn't call post surgical chemo excessively toxic.  He'll get 4 infusions; I had a total of 18 infusions and I don't have any adverse toxic symptoms. I think you are good to go.

Stay the course.

Tom

[hope16]

32 minutes ago, Tom Galli said:

hope16,

Four cycles of chemotherapy in twelve treatment weeks is pretty normal for post surgical chemotherapy. After this therapy, a post treatment scan will be administered and the results will determine if more treatment is warranted.  Your husband's tumor displays EGFR positive and that is a good thing because new tyrosine kinase inhibitor (TKI) drugs (erlotinib, gefitinib, afatinib and osimertinib) can treat his cancer should it return after post surgical chemotherapy.  

This approach does not seem like over-treatment.  It is a standard of care to administer post surgical chemotherapy for Stage IB resections and having TKI drugs in reserve is a very good thing because it is a different attack approach to bolster against a mutation recurrence. I wouldn't call post surgical chemo excessively toxic.  He'll get 4 infusions; I had a total of 18 infusions and I don't have any adverse toxic symptoms. I think you are good to go.

Stay the course.

Tom

thanks for your prompt response tom. But irrespective of the fact whether his caner returns, doctor wants to administer this drug to him for six months. This is what makes me wonder if it is over treament .

[Tom Galli]

hope16,

I think the doctor owes you a good explanation of why TKIs for 6 months.

Stay the course.

Tom

[hope16]

my husband's pdl1 test came negative. Does it mean he is not the candidate for immunotheapy?

 

[Kleo]

Hi Hope16,

I am not an expert on this but I have been reading up some as I'm about to start treatments myself shortly. From what I've read, for PD1-PDL1 checkpoint inhibitor drugs, a negative PDL1 expression would not necessarily exclude a patient from this type of immunotherapy treatment. It looks as though even in patients with negative PDL1 expression, there has still been response to treatments. Just as some PDL1 positive patients had no response. It appears that PDL1 expression is still not certain as far as a definitive predictive marker. So while it may not exclude him, your oncologist can determine best if he will benefit and which therapy he is most likely to respond to.

In my case,  they have made Durvamulab the standard of care following chemoradiation now for stage 3B unresectable lung cancer, regardless of PDL1 expression.

 

 

[hope16]

OK... Thanks Kleo