Oncology

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

Every medical oncologist wants to cure their patients. The problem has been when to stop. The general dictum that has guided medical oncology for 50 years can be summed up as “if some is good, more is better”. This regrettably may not be true. As a rule, patients will manifest benefit from therapy within 2-3 cycles. Thereafter, treatment is continued until complete remission, failure to respond, or intolerable toxicity. We witnessed the most glaring example of over treatment during the era of bone marrow transplantation for solid tumors which proved toxic and ineffective for most cancers, the exception being leukemias, myelomas and some lymphomas. Our preference is to use the right drugs from the start to achieve the best response with the least toxicity. Depending upon the tumor type, we complete treatment with 2 additional cycles beyond complete remission or in the highest risk cases, we may suggest a form of maintenance treatment. All of these therapies are administered with a very close attention to quality of life. Every medical oncologist wants to cure their patients. The problem has been when to stop. The general dictum that has guided medical oncology for 50 years can be summed up as “if some is good, more is better”. This regrettably may not be true. As a rule, patients will manifest benefit from therapy within 2-3 cycles. Thereafter, treatment is continued until complete remission, failure to respond, or intolerable toxicity. We witnessed the most glaring example of over treatment during the era of bone marrow transplantation for solid tumors which proved toxic and ineffective for most cancers, the exception being leukemias, myelomas and some lymphomas. Our preference is to use the right drugs from the start to achieve the best response with the least toxicity. Depending upon the tumor type, we complete treatment with 2 additional cycles beyond complete remission or in the highest risk cases, we may suggest a form of maintenance treatment. All of these therapies are administered with a very close attention to quality of life.

Every patient must have a definitive determination of the tissue of origin. This is accomplished at the time of a careful review of the biopsy and provides a diagnosis. The second step is to determine where the disease has spread to at the time of diagnosis. This is done through x-rays, PET scans and MRIs, and is known as “staging”. At this point, most physicians begin treatment.
We add a third dimension to our workup. Knowing where it came from (diagnosis) and where it has gone to (stage), our laboratory then seeks to determine what to do about it (chemosensitivity). That is where our group is different from many. Every patient must have a definitive determination of the tissue of origin. This is accomplished at the time of a careful review of the biopsy and provides a diagnosis. The second step is to determine where the disease has spread to at the time of diagnosis. This is done through x-rays, PET scans and MRIs, and is known as “staging”. At this point, most physicians begin treatment.
We add a third dimension to our workup. Knowing where it came from (diagnosis) and where it has gone to (stage), our laboratory then seeks to determine what to do about it (chemosensitivity). That is where our group is different from many.

This is a particularly controversial area of clinical medicine. While every patient desires close followup, the insurers and those engaged in the field of “evidence-based-medicine” point to the lack of survival benefit associated with the close monitoring of tumor markers and other harbingers of early relapse. It is indeed a dilemma, as both physicians and patients are comforted by negative workups and regular followups. It may, in the future, become necessary for patients to assume the costs of their followup visits after an adequate period of time has elapsed. As a rule, for most solid tumors, three years of followup with NED and certainly 5 years of followup with NED, is considered adequate. Despite this, some tumors, among them, ER+ breast cancers can manifest late relapses. This is a particularly controversial area of clinical medicine. While every patient desires close followup, the insurers and those engaged in the field of “evidence-based-medicine” point to the lack of survival benefit associated with the close monitoring of tumor markers and other harbingers of early relapse. It is indeed a dilemma, as both physicians and patients are comforted by negative workups and regular followups. It may, in the future, become necessary for patients to assume the costs of their followup visits after an adequate period of time has elapsed. As a rule, for most solid tumors, three years of followup with NED and certainly 5 years of followup with NED, is considered adequate. Despite this, some tumors, among them, ER+ breast cancers can manifest late relapses.