A Setback

Regular readers of this blog may have noticed that I haven't posted anything new since the beginning of 2014.

This year has brought  new challenges that I needed to get my head around before posting about it.  In short, the lung cancer has recurred.

In my late January CT scan, there were very small, lightly scattered cancer nodules in both lungs.  Dr. Bonomi had me double my Tarceva dosage to see if that would be sufficient to stabilize the cancer.  I was very hopeful that it would.

On March 12, six weeks later, new scans showed continued growth.  Although not at all aggressive, there were more and larger nodules than before.  The Tarceva was no longer suppressing the cancer effectively.  The cancer had developed a resistance to it.  This was not unexpected.  It is typical for cancer to eventually develop resistance to Tarceva.  Tarceva worked more than twice as long for me as is typical for this drug.  I got greedy and hoped it would last even longer.  So it goes.

Dr. Bonomi offered three options:  traditional chemotherapy, a 2nd generation targeted inhibitor (a newer drug similar to Tarceva) and clinical trials.  His personal recommendation is traditional chemotherapy.

I was able to quickly arrange for second opinions from two highly regarded lung cancer oncologists - one from Northwestern Memorial Hospital, the other an oncologist for both Evanston hospital and University of Chicago.  I had consultations with each of them yesterday.  They were consistent with Dr. Bonomi in the three options, although added information about the pros and cons of each approach.  In short:

• The 2nd generation targeted inhibitor, Afatinib (in combination with another drug called Ceduximab for increased effectiveness) was just introduced for general use about six or so months ago.  Success is 30-40% with similar but likely more severe side effects to Tarceva. 
• There is only one clinical trial in the Chicago area for which I am a potential candidate, but it is in the beginning of phase 2 and has no record yet as to likelihood of success.  A major downside for this trial is that it requires a 24-hour stay at the hospital every week to administer the drug.
• A chemotherapy cocktail of Alimta and Carboplatin with an EGFR antibody called Avastin for 4 cycles of treatment.  Each treatment is once every three weeks (equalling one cycle) for a total treatment period of 12 weeks.  After that, maintenance chemo indefinitely every three weeks.  Given my history with the EGFR mutation, the doctors say this has a 50% success rate, twice as high as those without the mutation.

The two doctors who gave me second opinions each suggested I get another biopsy now as it will probably be needed if I decide to participate in a clinical trial - now or in the future.  The approach to the biopsy was radically different between the two doctors.  One wanted to use a local anesthetic with a needle to biopsy a lymph node near my clavicle.  The other wanted to put me under general anesthesia and cut into the right lower lobe of my lung.  I don't plan to participate in a clinical trial now, based on what's available. In the future, I probably wouldn't want to participate in one unless the cancer once again progresses.  If that is the case, there should be tumors they can biopsy at that time.  Dr. Bonomi didn't think I needed one unless I want to do a clinical trial now.  He was concerned that none of my tumors that are in accessible locations are big enough (> or = 1 cm) to biopsy anyway.

Dr. Bonomi believes that it is better to try a treatment approach different from the receptor inhibiting qualities of Tarceva since the cancer now recognizes these inhibitors and has developed resistance to them.  Additionally, since I increased the Tarceva dosage, the side effects of rash, itching and stomach distress have increased.   These effects could potentially be even worse with this second generation inhibitor.  For that reason, his first choice would not be using Afatinib.

He also says some people find the side effects for chemo easier to take than those for Tarceva.  He says some people "sail through" the chemotherapy.  The most likely side effect of chemo is fatigue a couple days after treatment.  Three to four percent of patients experience nausea in spite of the anti-nausea medication that is part of the chemo cocktail.  Before each chemo treatment, they do blood work to ensure the white blood cell counts don't get too low, which would make me susceptible to serious infection.  There is a possibility of nose bleeds from the antibody (Avastin).

Based on the information from the three doctors, I think I will go with traditional chemo.  I really had hoped to avoid chemotherapy and desperately wish one of these alternatives had more to offer. But it looks like the lesser of all evils so that's the way it goes.