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Catherine Crossman

Keytruda Vs. Chemo & Radiation... I can't decide!

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This is for my mom - age 74 with numerous health issues just diagnosed in December with Primary Lung Adenocarcinoma, though the stage is not confirmed - they're guessing stage 4. She has a general oncologist locally, and a lung oncologist's second opinion with the best credentials at MD Anderson, but frankly, we're unhappy with both oncologists, but it's a toss up between which treatment regimen is best to try at least first - these are the facts:

Her current health issues:

Mild-moderate COPD with a bit of wheezing (though she doesn't feel like it bothers her at all - it's just her throat making a weird noise when she talks) once a month or so for a few days

smokes 8 cigarettes a day still (had one right after returning home after her lung biopsy)

facet arthritis in neck and vertebrae esp. lower back, stenosis, dextroscoliosis

fell down 1/29/19 on right hip which causes her immense pain daily

vascular degeneration

small vessel disease causing confusion and early signs of dementia - brother died of alzheimer's - massive anxiety and depression but refuses medication/anti-depressants

degenerative disc disease

varicose veins in legs, right carotid artery blockage around 70% (not enough for surgery yet given all of her other issues, but she did have a mini-stroke in 2015)

Slight colonic inflammation (as viewed on PET in 12/2018 - Gastro doc says doubtful it's cancer)

Aortic valve leak from previous radiation 21 years ago causing loud heart murmur

Prior breast cancer from 21 years ago (both mother and sister passed from same cancer) - stage 3B or so - told her 1-2 years to live, had full mastectomy of left breast & FAC Chemo & Radiation (she had 0 symptoms except hair loss, and felt almost no poisoning or weakness at all, amazingly at age 53) ...alive 21 years later - she had a strong will to live as I was 12 years old, and father died when I was 8 - only child.

 

General local oncologist: (same one from 21 years ago)

12/2018 - found 2.8 cm tumor in left lobe on ER visit for chest pain (in 2015, it was 1.1 cm and too small to worry about at that point) along with a few very small nodules on the other lobe and a mediastinal mass, oncologists scheduled numerous diagnostic work-ups, thinks it 'may' be in the rib bone and chest lymph nodes but no brain or other organ mets, ordered a lung biopsy, which was inconclusive and did not retrieve any malignant cells from a needle biopsy through the back (radiologist #1)

**I took her to a musculoskeletal oncologist to rule out bone mets, and he said he thinks it's just arthritic inflammation, not cancer - so he wouldn't stage it as 4 for bone.

2) 1/2019 - referred her to a thoracic surgeon for a thoracoscopy to get a biopsy, however after the pre-op cardiologist found the aortic valve leak which could lead to a heart attack under general anesthesia...

3) 2/2019 - we decided to pursue another needle biopsy requesting it from the front, and that led to a successful diagnosis almost 2 months later (radiologist #2). So he delayed everything by a month asking for a procedure, which was unnecessary due to the fault of the previous radiologist who told him he was confident another needle biopsy would not work.

4) 3/2019 - Mutation panel came back - 100% positive for PD-L1 on all tumor cells, and negative for all other mutations = strong contender for Keytruda, so his recommendation is to treat solely with Keytruda as he believes chemo at her age with her conditions would be more detrimental to her health. My concern is with all of her other issues, the COPD and arthritis especially, that if the immune system attacks healthy tissue, pneumonitis, colitis, or even lung collapse could happen, and we'd have to be watching her like a hawk for so many potentially fatal side effects, yet the nurse says most of her patients have no issues with keytruda other than minor flu-like symptoms. Medicare and supplemental BCBS covers all of it, and she is ready to go with it any day now once we decide.

 

MD Anderson Lung Oncologist with amazing background credentials:

3/2019 - He wants to order another diagnostic procedure, a bronchoscopy, to insure the lymph nodes are malignant in order to better stage the cancer. This will delay treatment further, could have issues with the anesthesia propofol causing respiratory depression with her COPD, and my question is what is the point at this stage -- there is a mass there in the mediastinum - it's probably malignant being so close to the lung and the heart - what else would it be? It seems like a waste to do this procedure, when the targeted therapy with 100% mutation could treat the entire system.

- Depending on if it's malignant, he says chemo and radiation - radiation only if a radiation therapist says she is eligible given her chest being scarred from 21 years prior. If not malignant, just chemo for the nodules in the lungs....

So... chemo is toxic, radiation would be damaging to her already damaged organs... and I don't think chemo on its own has a higher chance of survival with lung cancer vs. targeted therapy with that percentage mutation. But then again 21 years ago before all of her other issues popped up, she did amazing with the most aggressive chemo there is I'm told - FAC

 

But he is the best oncologist credential-wise and is at MD Anderson, which is supposed to be the best. I think maybe he steers away from immunotherapy because of the unknown risk of damaging and lasting side effects to the body vs. chemo, once you're done, you're done... but with her age and all her issues, it's just so difficult to decide on what to pick. Neither of them mentioned doing a combo of immuno/chemo, so it's either one or the other at this point in terms of what they'll order.

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Catherine,

Oh my your mom's case is complicated.

I'm going to summarize your post to confirm my understanding.  Your mom had adenocarcinoma that is confirmed by biopsy. The biopsy results also suggest high PD-L1 mutation that indicates suitability for immunotherapy as a successful treatment. Your mom has not had a PET scan.  She has significant health issues besides lung cancer, and doctors are mindful of these issues in designing a treatment plan.  One oncologist wants to treat only with immunotherapy.  One wants another biopsy (to check lymph node involvement) to confirm staging and is leaning towards chemo and radiation as a treatment plan.

You need help deciding which treatment is best.  Here is the way I'd approach your decision. Be mindful, however, I'm not a doctor!  Your mom's complicating health problems rule out surgery therefore staging her lung cancer becomes almost irrelevant.  Generally, staging is used to answer but one question: surgery yes or no.  I think you've already got a no surgery answer. Moreover, there is a non-invasive way to confirm staging: a PET scan and I note that has not been performed.

Immunotherapy with the drug Pembrolizumab (trade name -- Keytruda) is FDA approved as first line treatment (national standard of care) for people with metastatic NSCLC whose cancer shows greater than or equal to 50% PD-L1 expression Tumor Proportion Score with no EGFR or ALK mutation. I believe your mom fits these conditions. I believe combination chemotherapy and immunotherapy is not suggested because of your mom's very high PD-L1 expression score. 

Your concern about immunotherapy's adverse effect on complicating health problems is valid.  It is also valid for conventional chemotherapy.  Any form of treatment given your mom's complicating health concerns carries risk. Which of these treatment alternatives carries less risk? I wouldn't know. I suspect neither of your mom's oncologists would know with certainty either.

Unfortunately, with complicating health problems undergoing cancer treatment can be an iffy proposition.  You are left with a tough, uncertain decision -- two actually: to treat, and if yes, how to treat. I'm sorry I can't be of more help.

Stay the course.

Tom

 

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Catherine-

I thought I would share about my mom since she has had both chemo + radiation and Keytruda + chemo, then onto Keytruda alone.  My mom is 64 years old and has lots of health issues too - rheumatoid arthritis, COPD, sleep apnea, diabetes, constant pain from fused neck and back.  Her heart and brain (most days) are pretty healthy.  

My mom was diagnosed in 2015. She originally had a lobectomy, but the surgeon couldn't get a lymphnode that was involved, so she went on to have chemo and radiation. She responded to treatment quite well. Radiaton was a breeze, she ended up with a slight sore throat toward the end of treatment.  Chemo wasn't too bad for her.  She had severe acid reflux, but once that was under control, she only felt fatigued.  Chemo brain did not kick in until she was almost done with treatment and lasted for about 6 months afterward.  She completed treatment and was doing 3 months scans.  Her cancer came back about 1 year later.  This time, Keytruda + Chemo was recommended.  My mom has a very high PD-L1 rate and was a great candidate for Keytruda.  A few months prior to her treatment plan, studies showed that adding 2 kinds of chemo to Keytruda increases the effects.  Since my mom did so well with chemo the first time, we didn't hesitate to agree to adding chemo to her treatment.  Well, this time, she did not fare as well.  She was in and out of the hospital with various issues and felt horrible for the most of 6 months - flu-like symptoms, fatigue, etc..  But the treatment worked.  She went on to Keytruda alone for about 10 months. The main side effects were some fatigue and a rash.   She had to stop because she had swelling in her bowel, intestines, and stomach that were causing horrible issues.  She's been off of Keytruda since October 2018 and so far, things still look good, cancer-wise.  

I can't tell you which treatment plan to choose, but maybe my mom's experience can shed some light on your options.

Take care,

Steff

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