Cancer Q&A
"Lung Cancer"
My family member has stage 4 EGFR lung cancer and has been taking the first-generation targeted drug IRESSA for a year and a half. However, a brain MRI last month revealed brain metastases (approximately 7mm). The doctor recommended local radiotherapy. I would like to ask what options are available for radiotherapy at a public hospital? The doctor said it wouldn't be Gamma Knife, but rather a similar 3D radiotherapy technology. I would like to ask if you know what types of radiotherapy are commonly used in public hospitals nowadays?Are the side effects minimal? What is the chance of recurrence after local radiotherapy? I'm currently awaiting blood test results to see if there's a T790M lesion. If so, I can switch to third-generation targeted therapy, but I'm worried the T790M might not be detected. How accurate are current blood tests? If it's not detected, is it worthwhile to have a tissue sample taken for testing, and how much difference in accuracy is there between the two?
Answer:
If a small number of new brain metastases occur after taking targeted therapy, local brain radiotherapy can be performed to control the tumor, and then the original targeted therapy can be continued, or another targeted therapy with stronger brain penetration can be switched immediately.
There are many different techniques available for localized brain radiotherapy. Standard practice generally involves using a linear accelerator for stereotactic radiotherapy or a gamma knife for stereotactic radiosurgery.
Although both are methods of external radiation therapy, they differ in patient fixation methods, pre-treatment localization methods, treatment duration, and even cost. There is also a lack of prospective clinical research data directly comparing their therapeutic efficacy. However, when the number of tumors is small (e.g., 4 or fewer) and there are no particularly high-risk nerve tissues to avoid, most doctors generally consider the therapeutic efficacy and safety of both methods to be roughly equivalent.
If you have any questions about the instruments or methods used, it is recommended that you communicate directly with your attending physician to clearly understand the treatment methods to be performed.
Blood biopsies typically have a sensitivity of around 80%. However, if only the brain tumor is affected while other tumors in the body are well-controlled, the sensitivity drops significantly. When a blood test is negative, the standard recommendation is to perform a tissue examination to rule out the approximately 30% chance of actually having T790M. However, in patients with isolated, malignant brain tumors, the risk of brain surgery to detect T790M is too high, and it is generally not recommended.
There are two options: continue using the original targeted therapy, or switch directly to a third-generation targeted therapy. If financially feasible, the latter is the better option.
My husband was diagnosed with stage IV lung adenocarcinoma in March 2019. A positron emission tomography (PET) scan at the end of February showed a 7.9cm tumor in his lung, with metastasis to surrounding lymph nodes and the spine. He initially received five sessions of radiotherapy in the QE oncology department for spinal pain relief, which provided some relief. Because lung tissue tests showed no gene mutations (he is a smoker), targeted therapy was not an option. We considered immunotherapy, but due to a test result below 1%, it was also not an option. Chemotherapy was the only option; he received four cycles of Alimta + Carbonation. After one chemotherapy session, his blood cancer cell count dropped from over 18 to over 8.However, after the second round of chemotherapy, the cancer cell index in the blood test rose to over 12. To make matters worse, the tumor had metastasized to the cervical lymph nodes. The doctor said that the first-line drugs were already the best available, and the chemotherapy drugs could only be switched to one drug, which would need to be taken once a week. The side effects would also be more than before, requiring the use of steroids, which would affect the stomach and could potentially cause stomach ulcers (my husband already has stomach ulcers and trigeminal neuralgia, and he has to take medication for these conditions).The doctor said that second-line treatment is effective for only 1 or 2 out of 10 patients. The success rate of second-line immunotherapy is similar, and it's quite expensive; out-of-pocket medication is estimated to cost around 50,000 yuan per month. In addition, he frequently suffers from fever and anemia, requiring hospitalization for blood transfusions. Even in the hospital, he has a fever, and the doctor won't approve his discharge. There are currently no treatment options available. Doctor, what treatments are possible for my husband in this situation? Can cervical lymph nodes be treated with electrotherapy? Do you have any suggestions or advice for us?
According to the latest medical research data, for patients with stage IV lung adenocarcinoma, first-line treatment can be combined with chemotherapy drugs and immunotherapy. There is no need to pay attention to the level of PDL-1 protein. The level of protein only reflects the extent of benefit from using immunotherapy, but it is more effective than chemotherapy drugs alone, regardless of the level.
If immunotherapy is not used as first-line treatment, then it is the most effective second-line treatment. Although the chance of tumor shrinkage is only 20% at most, immunotherapy can ultimately enable 10% to 15% of patients to control their tumors for more than five years, and it is believed that many of these patients have been cured.
For second-line immunotherapy drugs, the dosage can be calculated based on weight, and some patients may only need to pay half the cost. If financial difficulties exist, regardless of weight, using half the dosage should preserve 80-90% of the drug's efficacy. Consult your doctor for more details.
In addition, traditional second-line chemotherapy drugs should be administered if the patient's condition permits, as they also have certain effects in treating tumors and alleviating symptoms.
Generally, chemotherapy or immunotherapy drugs should not be administered when a patient has a fever. The underlying infection must be treated before further treatment can proceed. However, in some patients, the fever is related to an inflammatory response caused by tumor spread. In such cases, anti-inflammatory and antipyretic drugs can be used, and chemotherapy or immunotherapy can continue as usual.
The patient is a nearly 70-year-old male, a smoker who quit over ten years ago, with a history of hepatitis B, and limited mobility requiring a wheelchair. He has been diagnosed with stage 4 lung cancer. Initially, a chest X-ray revealed a nodule in his right lung. A PET scan in mid-June confirmed a tumor, and the oncologist referred him to a pulmonologist to assess surgical feasibility. In October, he underwent pulmonary function testing, and in early November, he underwent minimally invasive surgery. However, the pulmonologist stated that the cancer had spread to the pleural metastasis, making surgery impossible; only a tissue biopsy could be performed. The cancer was stage 4, and he needed to return to the oncology department for follow-up and treatment. In mid-November, he saw an oncologist who diagnosed squamous cell carcinoma (T1c N0 M1a), with a tumor approximately 4cm in the right upper lobe that had spread to the pleural metastasis. Surgery was not an option, and there were no suitable targeted therapies available. Chemotherapy or testing for immunotherapy were the only options. Questions: 1. Is the spread to the pleural metastasis considered a serious condition? 1. Are there any successful treatment cases? I'm very worried because I heard it's stage 4, and it went from being able to try surgery to discover during the operation that it had spread to the pleura, making surgery impossible. 2. Chemotherapy uses Gemcitabine and Carboplatin, with two injections every three weeks for one course of treatment, for a total of 4-6 courses. Will the side effects be severe? Can I stop if it becomes too painful midway? Does choosing to do it or not make a big difference to the condition? 3. The doctor said that immunotherapy costs 30,000-40,000 every three to four weeks, which is 10,000 per week, and it's for long-term use. It's very difficult to afford financially. Is there any assistance? Is it really effective? Is it worth trying? 4. The doctor said there are no suitable targeted drugs available. Does this mean there is no gene mutation? Or is there no targeted drug available for squamous cell carcinoma? 5. It seems that chemotherapy is the only option now. Should I consult a private doctor for advice? Or are they all similar? Since the patient hopes to have surgery, is the chance of surgery after chemotherapy high? 6. Is it possible to try both traditional Chinese medicine and Western medicine treatments simultaneously? I've heard that shark cartilage and the ketogenic diet can effectively fight cancer, is that true?
Answer:
1. Spreading to the pleura indicates stage four, which is further subdivided into A, B, and C categories. Spreading to the pleura falls under stage 4A, which generally offers a better prognosis.
2. Most side effects are within an acceptable range. If the side effects are too severe or you feel too uncomfortable, you can reduce the dosage or stop taking the medication immediately.
3. Once immunotherapy begins, if it is effective, treatment will generally continue. If treatment can be completed for two years, discontinuation will be considered.
4. Squamous lung cancer has fewer available targeted therapies than lung adenocarcinoma, but this does not mean it is impossible. There is a 30% chance of finding suitable gene mutations, but for most types of gene mutations, the availability of targeted therapies is limited and their efficacy is relatively low; these are generally considered for later-line treatment.
5. Treatment plans are influenced by many factors, including the stage of the tumor, the patient's physical condition and wishes, and also depend on the oncologist's understanding of various medical literature. Please choose which doctor to see based on your level of trust and affordability.
6. There is currently no clinical data showing that this type of diet can fight lung cancer.
Hello doctor, my mother is 70 years old and needs to undergo chemotherapy for lung cancer. We just discovered that she is allergic to the steroids she takes before chemotherapy, experiencing rapid heartbeat, skin irritation, numbness in her legs, anxiety, and confusion. Now the doctor will not prescribe steroids for chemotherapy. Are there any other medications that can help reduce the side effects of chemotherapy?
Answer:
Steroids used before chemotherapy generally have several benefits. First, they can reduce drug sensitivity. Second, they have an antiemetic effect. Third, they can reduce edema caused by certain chemotherapy drugs. Regarding the first benefit, other medications, such as Benadryl, can be used as substitutes. However, if the chance of a sensitization reaction to the original medication is low, additional medication is not necessary. Regarding the second benefit, many very strong antiemetics are available. Simple oral administration can provide strong antiemetic effects, sometimes even stronger than injected antiemetics. Therefore, even without taking steroids, vomiting may not occur, so you don't need to worry too much. Finally, regarding edema, the chemotherapy drugs your mother is using may not necessarily cause edema. If it does occur, common oral anti-edema pills, such as furosemide (lasix), can provide relief.