Lung Cancer

Hi, I had two tumors one each in upper and lower right lobes. First, they did the tattoos and then the cast. The tattoo shows where the radiation is to be targeted. The cast is for your use only while receiving SRS so you don't move. You lay on the material and they wet it down, then shape it to your body. It dries quickly. Then you lay in it every time. I had 4 treatments for each tumor lasting 20 mins. each. They gave me a break in between. I did end up with esophagitis, very bad sore throat and hard to swallow. I used the magic mouthwash and it was gone within 10 days. I also used Prilosec for heartburn. I wasn't tired and never felt sick. My problem now is radiation scarring to the pectoral muscle and under the armpit. Though targeted, you have to remember that it has to go in and come back out somewhere. This was due to the location of the one tumor, so basically unavoidable. I have pain when I overdo it, but I'm doing very well overall. I started chemo within two weeks and I'm presently NED. Hi, I had two tumors one each in upper and lower right lobes. First, they did the tattoos and then the cast. The tattoo shows where the radiation is to be targeted. The cast is for your use only while receiving SRS so you don't move. You lay on the material and they wet it down, then shape it to your body. It dries quickly. Then you lay in it every time. I had 4 treatments for each tumor lasting 20 mins. each. They gave me a break in between. I did end up with esophagitis, very bad sore throat and hard to swallow. I used the magic mouthwash and it was gone within 10 days. I also used Prilosec for heartburn. I wasn't tired and never felt sick. My problem now is radiation scarring to the pectoral muscle and under the armpit. Though targeted, you have to remember that it has to go in and come back out somewhere. This was due to the location of the one tumor, so basically unavoidable. I have pain when I overdo it, but I'm doing very well overall. I started chemo within two weeks and I'm presently NED.

There are a variety of physician preferences for following tumors during therapy, but the approach used in most clinical trials is a standard CT scan every other cycle of chemotherapy. There is increasing use of PET scanning, but this is experimental, expensive, and there is a high risk of getting misleading information from a PET that could result in inappropriate changes in therapy. There are a variety of physician preferences for following tumors during therapy, but the approach used in most clinical trials is a standard CT scan every other cycle of chemotherapy. There is increasing use of PET scanning, but this is experimental, expensive, and there is a high risk of getting misleading information from a PET that could result in inappropriate changes in therapy.

These drugs are being tested in clinical trials after surgery or chemoradiation in stage I to 3 lung cancer, but the evidence available so far do not demonstrate that they work in this setting. I do not recommend using these drugs in the curative-intent setting unless as part of a clinical trial. These drugs are being tested in clinical trials after surgery or chemoradiation in stage I to 3 lung cancer, but the evidence available so far do not demonstrate that they work in this setting. I do not recommend using these drugs in the curative-intent setting unless as part of a clinical trial.

Xalkori is very successful in causing tumor shrinkage in most patients whose tumors have an ALK fusion. Efficacy is usually measured by tumor shrinkage, time to progression or survival. Xalkori is very successful in causing tumor shrinkage in most patients whose tumors have an ALK fusion. Efficacy is usually measured by tumor shrinkage, time to progression or survival.

There are many sources of information about these complementary therapies on the internet, but most are self-serving (the source of the information stands to profit from the alternative therapy). I am convinced that modern cancer therapies can be effective and that they should not be delayed to try complementary therapies. If there are no standard therapies available, complementary therapies are reasonable. This does not mean that a lung cancer patient should not try to eat a healthy diet during therapy, but I recommend that patients do not take megadoses of any natural or alternative supplement. There are many sources of information about these complementary therapies on the internet, but most are self-serving (the source of the information stands to profit from the alternative therapy). I am convinced that modern cancer therapies can be effective and that they should not be delayed to try complementary therapies. If there are no standard therapies available, complementary therapies are reasonable. This does not mean that a lung cancer patient should not try to eat a healthy diet during therapy, but I recommend that patients do not take megadoses of any natural or alternative supplement.

Family members with cancer always raise your risk of cancer by some amount, particularly if smoking is not involved. There is a rare inherited mutation in the EGFR gene that can result in a significant increase in risk in carriers. If your mother had certain EGFR mutations in her lung cancer the probability of an inherited mutation is greater.
Family members with cancer always raise your risk of cancer by some amount, particularly if smoking is not involved. There is a rare inherited mutation in the EGFR gene that can result in a significant increase in risk in carriers. If your mother had certain EGFR mutations in her lung cancer the probability of an inherited mutation is greater.

The biggest difference that histology makes is in the determination of small cell versus non-small cell cancer. After that, pemetrexed chemotherapy has been shown to be ineffective in patients with the squamous type of non-small cell lung cancer. The biggest difference that histology makes is in the determination of small cell versus non-small cell cancer. After that, pemetrexed chemotherapy has been shown to be ineffective in patients with the squamous type of non-small cell lung cancer.

Every patient is different and every tumor is different. The first step is determining what kind of cancer the patient has and where has it spread. The most important first decision is whether there is a possibility of cure, and if so, what is the best option for the patient to achieve that - surgery with or without adjuvant therapy, chemotherapy and radiation, or stereotactic body radiotherapy. If cure is a possibility, then more aggressive and toxic treatments are reasonable than if the goal is prolonging life with cancer rather than curing it. If the cancer is incurable then the most important next step is determining whether the tumor has a mutation in the EGFR or ALK genes. If not then I determine the optimum chemotherapy regimen. At every step I try to determine if there is a clinical trial available. Every patient is different and every tumor is different. The first step is determining what kind of cancer the patient has and where has it spread. The most important first decision is whether there is a possibility of cure, and if so, what is the best option for the patient to achieve that - surgery with or without adjuvant therapy, chemotherapy and radiation, or stereotactic body radiotherapy. If cure is a possibility, then more aggressive and toxic treatments are reasonable than if the goal is prolonging life with cancer rather than curing it. If the cancer is incurable then the most important next step is determining whether the tumor has a mutation in the EGFR or ALK genes. If not then I determine the optimum chemotherapy regimen. At every step I try to determine if there is a clinical trial available.

Medical oncologist are routinely involved in the care of patients who are diagnosed with non small cell lung cancer. No matter what stage (I-IV), our practice at Beth Israel is that a medical oncologist should be involved at least initially in all patients diagnosed with lung cancer. Medical oncologist are routinely involved in the care of patients who are diagnosed with non small cell lung cancer. No matter what stage (I-IV), our practice at Beth Israel is that a medical oncologist should be involved at least initially in all patients diagnosed with lung cancer.

Genetic mutations play a key role in NSCLC. Identifying certain, key mutations can help select targeted therapy. The two most important mutations in lung cancer right now are the EGFR and EML-4ALK mutation and are found in the subtype of lung cancer called adenocarcinoma. These mutations are more commonly found in female, asian, non-smokers. However, they are also found in smokers and males, but to a lesser degree.

Patients with the EGFR mutation are generally treated with a drug (pill) called Tarceva as first line treatment, rather than chemotherapy. Similarly, patients with the EML-4 ALK mutation are treated with a recently approved drug (pill) called Xalqori (Crizotinib). Generally patients with these mutations who are treated with the appropriate drug do very well when compared to patients who don't have the mutation and are treated with chemotherapy

Due to the dramatic responses with the use of these drugs when a mutation is identified, it is important to test for these mutation at diagnosis. Generally, when the initally biopsy is done, I make sure that there is enough material left over to send for molecular testing. It takes roughly 2 weeks to get the results back, so based on patient preference, I may start the patient on chemotherapy until the results come back.

To note, the testing of these mutations should routinely be performed in patients with stage IV NSCLC, not in patients with stage I-III (yet). Outside of a clinical trial, there is just not enough evidence yet on how to use these molecular markers in stage I to III NSCLC although this may change very soon. Genetic mutations play a key role in NSCLC. Identifying certain, key mutations can help select targeted therapy. The two most important mutations in lung cancer right now are the EGFR and EML-4ALK mutation and are found in the subtype of lung cancer called adenocarcinoma. These mutations are more commonly found in female, asian, non-smokers. However, they are also found in smokers and males, but to a lesser degree.

Patients with the EGFR mutation are generally treated with a drug (pill) called Tarceva as first line treatment, rather than chemotherapy. Similarly, patients with the EML-4 ALK mutation are treated with a recently approved drug (pill) called Xalqori (Crizotinib). Generally patients with these mutations who are treated with the appropriate drug do very well when compared to patients who don't have the mutation and are treated with chemotherapy

Due to the dramatic responses with the use of these drugs when a mutation is identified, it is important to test for these mutation at diagnosis. Generally, when the initally biopsy is done, I make sure that there is enough material left over to send for molecular testing. It takes roughly 2 weeks to get the results back, so based on patient preference, I may start the patient on chemotherapy until the results come back.

To note, the testing of these mutations should routinely be performed in patients with stage IV NSCLC, not in patients with stage I-III (yet). Outside of a clinical trial, there is just not enough evidence yet on how to use these molecular markers in stage I to III NSCLC although this may change very soon.

Genetic mutations play a key role in NSCLC. Identifying certain, key mutations can help select targeted therapy. The two most important mutations in lung cancer right now are the EGFR and EML-4ALK mutation and are found in the subtype of lung cancer called adenocarcinoma. These mutations are more commonly found in female, asian, non-smokers. However, they are also found in smokers and males, but to a lesser degree.

Patients with the EGFR mutation are generally treated with a drug (pill) called Tarceva as first line treatment, rather than chemotherapy. Similarly, patients with the EML-4 ALK mutation are treated with a recently approved drug (pill) called Xalqori (Crizotinib). Generally patients with these mutations who are treated with the appropriate drug do very well when compared to patients who don't have the mutation and are treated with chemotherapy

It is important to note, that while other mutations in lung cancer do exist and can be identified (KRAS mutation, PIK-3 mutation, MET to name a few), there are no approved drugs that target these mutations like Tarceva and Xalqori do for EGFR and EML-4ALK and thus patients with these mutations are treated with standard chemotherpay. That said, there are several clinical trials open looking a new drugs that target these mutations. Genetic mutations play a key role in NSCLC. Identifying certain, key mutations can help select targeted therapy. The two most important mutations in lung cancer right now are the EGFR and EML-4ALK mutation and are found in the subtype of lung cancer called adenocarcinoma. These mutations are more commonly found in female, asian, non-smokers. However, they are also found in smokers and males, but to a lesser degree.

Patients with the EGFR mutation are generally treated with a drug (pill) called Tarceva as first line treatment, rather than chemotherapy. Similarly, patients with the EML-4 ALK mutation are treated with a recently approved drug (pill) called Xalqori (Crizotinib). Generally patients with these mutations who are treated with the appropriate drug do very well when compared to patients who don't have the mutation and are treated with chemotherapy

It is important to note, that while other mutations in lung cancer do exist and can be identified (KRAS mutation, PIK-3 mutation, MET to name a few), there are no approved drugs that target these mutations like Tarceva and Xalqori do for EGFR and EML-4ALK and thus patients with these mutations are treated with standard chemotherpay. That said, there are several clinical trials open looking a new drugs that target these mutations.

Patients with stage IV NSCLC are first treated with platinum chemotherapy which is a platinum drug (either carboplatin or cisplatin) plus another drug (Gemcitabine, Paclitaxel, Docetaxel or Alimta). At some point, unfortunately, patients will progress and their tumor will grow after the first type of chemotherapy is given. Generally at that point, a second line drug is used and the platinum doublet is abandoned.

There are three approved second line drugs (Tarceva, Alimta, Docetaxel) for NSCLC but their use is dependent on what a patient got in the first line. For instance, if a patient received Carboplatin and Alimta as a first line regimen, then the second line possibilities would be Tarceva or Docetaxel. Sometimes the drug Gemcitabine is also offerred. Unlike first line therapy, second line therapy is generally just one drug, not two. Response rates (the percentage of patients whose tumors shrink) is lower in the second line (only 10 to 15% of patients' tumors will shrink) depending on the patient the drug used. While those numbers are small, there is ample data that patients who go on to receive a second line drug live longer than those that don't receive any second line drug. Patients with stage IV NSCLC are first treated with platinum chemotherapy which is a platinum drug (either carboplatin or cisplatin) plus another drug (Gemcitabine, Paclitaxel, Docetaxel or Alimta). At some point, unfortunately, patients will progress and their tumor will grow after the first type of chemotherapy is given. Generally at that point, a second line drug is used and the platinum doublet is abandoned.

There are three approved second line drugs (Tarceva, Alimta, Docetaxel) for NSCLC but their use is dependent on what a patient got in the first line. For instance, if a patient received Carboplatin and Alimta as a first line regimen, then the second line possibilities would be Tarceva or Docetaxel. Sometimes the drug Gemcitabine is also offerred. Unlike first line therapy, second line therapy is generally just one drug, not two. Response rates (the percentage of patients whose tumors shrink) is lower in the second line (only 10 to 15% of patients' tumors will shrink) depending on the patient the drug used. While those numbers are small, there is ample data that patients who go on to receive a second line drug live longer than those that don't receive any second line drug.

Chemotherapy for lung cancer has currently undergone several changes. The standard chemotherapy for patients with stage IV non-small cell lung cancer (NSCLC) is called a platinum doublet. That is either Carboplatin or Cisplatin in combination with another drug (generally the chemotherapy drugs taxol, gemcitabine, or pemetrexed).

However, recently, it appears that certain chemotherapy works better based on the subtype or histology of non small cell lung cancer that you have. This is called histology based treatment. Basically the data published suggested that if you select the chemotherpay based on histology, that patients do better. The two types of histologies of non-small cell lung cancer are adenocarcinoma and sqaumous cell. Based on recent data, it is my practice to give adenocarcinoma (the most common type) the following chemotherapy -- Cisplatin or Carboplatin in combination with a drug called Pemetrexed (Alimta). In addition, if adenocarcinoma, I generally add another drug called Avastin (for a total of three drugs). If patients have sqaumous cell, I generally offer Cisplatin or Carboplatin in combination with Gemcitabine. In summary, adenocarcinoma generally gets three drugs -- 1. Platinum (cisplatin or carboplatin), 2. Alimta and 3. Avastin (if elgible) and patients with sqaumous gets another (Cisplatin or Carboplatin) + Gemcitabine. Other acceptable standards include Platinum (Carboplatin or Cisplatin) + Taxol

Recently, there has been renewed interest to look at other markers (ERCC1, RRM, TS) in lung cancer to help select chemotherapy but thus far, this has not been proven to be better than the standard (these studies are ongoing). In mutational testing has become routine for patients who have adenocarcinoma. The two mutations that are tested for are the EGFR mutation and the ELM-4 mutation. Patient who have this mutation are generally offered oral drugs and not chemotherpay as discussed above Chemotherapy for lung cancer has currently undergone several changes. The standard chemotherapy for patients with stage IV non-small cell lung cancer (NSCLC) is called a platinum doublet. That is either Carboplatin or Cisplatin in combination with another drug (generally the chemotherapy drugs taxol, gemcitabine, or pemetrexed).

However, recently, it appears that certain chemotherapy works better based on the subtype or histology of non small cell lung cancer that you have. This is called histology based treatment. Basically the data published suggested that if you select the chemotherpay based on histology, that patients do better. The two types of histologies of non-small cell lung cancer are adenocarcinoma and sqaumous cell. Based on recent data, it is my practice to give adenocarcinoma (the most common type) the following chemotherapy -- Cisplatin or Carboplatin in combination with a drug called Pemetrexed (Alimta). In addition, if adenocarcinoma, I generally add another drug called Avastin (for a total of three drugs). If patients have sqaumous cell, I generally offer Cisplatin or Carboplatin in combination with Gemcitabine. In summary, adenocarcinoma generally gets three drugs -- 1. Platinum (cisplatin or carboplatin), 2. Alimta and 3. Avastin (if elgible) and patients with sqaumous gets another (Cisplatin or Carboplatin) + Gemcitabine. Other acceptable standards include Platinum (Carboplatin or Cisplatin) + Taxol

Recently, there has been renewed interest to look at other markers (ERCC1, RRM, TS) in lung cancer to help select chemotherapy but thus far, this has not been proven to be better than the standard (these studies are ongoing). In mutational testing has become routine for patients who have adenocarcinoma. The two mutations that are tested for are the EGFR mutation and the ELM-4 mutation. Patient who have this mutation are generally offered oral drugs and not chemotherpay as discussed above

The tests that generally used to determine is lung cancer has travelled to other parts of the body (metastasized) is either a CT scan of the chest, abdomen and pelvis or more commonly a PET scan. A PET scan in a cancer scan of the whole body that picks up tumor growth. Generally, a PET scan is considered the standard of care for patients in the initial workup of their cancer. However, if a patient has already been diagnosed and treated, either a CT scan of chest/abdomen/pelvis or a PET scan can be used. Finally, a brain MRI is generally done as well to make sure the cancer has not moved to the brain. The tests that generally used to determine is lung cancer has travelled to other parts of the body (metastasized) is either a CT scan of the chest, abdomen and pelvis or more commonly a PET scan. A PET scan in a cancer scan of the whole body that picks up tumor growth. Generally, a PET scan is considered the standard of care for patients in the initial workup of their cancer. However, if a patient has already been diagnosed and treated, either a CT scan of chest/abdomen/pelvis or a PET scan can be used. Finally, a brain MRI is generally done as well to make sure the cancer has not moved to the brain.

All patients with stage IV NSCLC who have the most common type, called adenocarcinoma, should have their tumor tested for at least two mutations prior to treatement. These mutations are called EGFR and ELM4-ALK and mutually exclusive (they don't ever occur together). Patients who have the EGFR mutation should be treated with a drug called Tarceva, while those who have the ELM4-ALK mutation should be treated with a relatively new comer, called Crizotinib. This is a new era in lung cancer where we are able to identify a mutation and treat with a drug targeting the mutation, rather than standard chemotherapy. Keep in mind only 15% of patients with adenocarcinoma will have the EGFR mutation and even less have the ELM4-ALK mutation (3-5%), so chances are that you will not have the mutation. Once the mutation is identified and you are treated with the appropriate drug, the mutation does not need to be tested again. That said, there is a significant interest in rebiopsying patients who progress (their tumor grows) on the drugs mentioned above (Tarceva or Crizotinib) to see if the mutation in the tumor has changed to something different. This is being done in clinical trials but is not, to date, considered the standard of care. So, in short, once your tumor has been identified as having the mutation and you are started on the drug, it does not need to be tested again unless part of a clinical trial and you progress on the drug. All patients with stage IV NSCLC who have the most common type, called adenocarcinoma, should have their tumor tested for at least two mutations prior to treatement. These mutations are called EGFR and ELM4-ALK and mutually exclusive (they don't ever occur together). Patients who have the EGFR mutation should be treated with a drug called Tarceva, while those who have the ELM4-ALK mutation should be treated with a relatively new comer, called Crizotinib. This is a new era in lung cancer where we are able to identify a mutation and treat with a drug targeting the mutation, rather than standard chemotherapy. Keep in mind only 15% of patients with adenocarcinoma will have the EGFR mutation and even less have the ELM4-ALK mutation (3-5%), so chances are that you will not have the mutation. Once the mutation is identified and you are treated with the appropriate drug, the mutation does not need to be tested again. That said, there is a significant interest in rebiopsying patients who progress (their tumor grows) on the drugs mentioned above (Tarceva or Crizotinib) to see if the mutation in the tumor has changed to something different. This is being done in clinical trials but is not, to date, considered the standard of care. So, in short, once your tumor has been identified as having the mutation and you are started on the drug, it does not need to be tested again unless part of a clinical trial and you progress on the drug.

Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on. Treatment options are dependent on a variety of factors including the stage, a patient's other medical conditions, and a patient's understanding of these options. For example, there are now certain conditions/situations where by stereotactic body radiation therapy (SBRT) may be an alternative to surgery. Our physicians always take their time in going through all modalities and side effects with our patients so that they can make the most educated decision for themselves, and be comfortable with the treatment they decided on.

The most common side effects of crizotinib (Xalkori) are:
- Gastrointestinal side effects which include nausea, vomiting, decreased appetite, diarrhea, constipation
- Swelling of hands and feets (edema)

Less common side effects include:
- Mild dizziness
- Fatigue
- Insomnia
- Mild rash
- Numbness or tingling
- Cold symptoms
- Arthralgia and back pain


Side effects that are not as common but may present problems are:
- Pneumonitis
- Hepatic liver abnormalities (elevated ALT (alanine aminotransferase) and AST (aspartate aminotransferase) levels
- QT Prolongation which is an irregular heart rhythm

Crizotinib (Xalkori) side effects vary greatly from patient to patient depending on different issues including patient history, existing conditions, other prescribed medications the patient is taking, and stage of disease. Some people experience minimal side effects, while others may experience severe side effects.

If the side effects from Xalkori are severe, you may speak to your physician about medications to treat the side effects. It is important to notify your physician if and when you develop any side effects and to listen to your body and call your healthcare provider if something seems amiss.

Websites that may provide more information include:

http://www.drugs.com/xalkori.html
http://www.pfizerpro.com/hcp/xalkori_home??source=google&HBX_PK=s_+xalkori&HBX_OU=50&o=69985681|245244793|0&skwid=43700003139871797
http://www.rxlist.com/xalkori-drug/side-effects-interactions.htm The most common side effects of crizotinib (Xalkori) are:
- Gastrointestinal side effects which include nausea, vomiting, decreased appetite, diarrhea, constipation
- Swelling of hands and feets (edema)

Less common side effects include:
- Mild dizziness
- Fatigue
- Insomnia
- Mild rash
- Numbness or tingling
- Cold symptoms
- Arthralgia and back pain


Side effects that are not as common but may present problems are:
- Pneumonitis
- Hepatic liver abnormalities (elevated ALT (alanine aminotransferase) and AST (aspartate aminotransferase) levels
- QT Prolongation which is an irregular heart rhythm

Crizotinib (Xalkori) side effects vary greatly from patient to patient depending on different issues including patient history, existing conditions, other prescribed medications the patient is taking, and stage of disease. Some people experience minimal side effects, while others may experience severe side effects.

If the side effects from Xalkori are severe, you may speak to your physician about medications to treat the side effects. It is important to notify your physician if and when you develop any side effects and to listen to your body and call your healthcare provider if something seems amiss.

Websites that may provide more information include:

http://www.drugs.com/xalkori.html
http://www.pfizerpro.com/hcp/xalkori_home??source=google&HBX_PK=s_+xalkori&HBX_OU=50&o=69985681|245244793|0&skwid=43700003139871797
http://www.rxlist.com/xalkori-drug/side-effects-interactions.htm