The Verdict on Consolidation

Yoko and I met with Dr. Lunin today to discuss what the next steps should be with respect to treatment. I will give you the bottom line and then tell you how we arrived at this conclusion.

We are going to continue the chemo using a drug called vinorelbine together with cisplatin. (I could never be a doctor as I can not pronounce the names of half the drugs on the market... ) The consolidation treatment is going to go for 16 weeks. We plan to follow the regiment of a study that was published in the New England Journal of Medicine in the June 23, 2005 edition. If you want to read the details: http://content.nejm.org/content/vol352/issue25/index.shtml or let me know and I will e-mail you the article as a pdf file.

We will start the new regiment on Friday, February 15th and continue every Friday until May 30th. According to Dr. Lunin, the biggest side effect from the new drug regiment will be nuropathy (loss of feeling) in the extremities, which happens in about half the cases. The longer the chemo goes on, the more likely it is that I will experience some nuropathy. Other than that, as far as side effects, we would not expect that this course of treatment would be much different than the initial round. That is good news because it means that I should be able to continue on without any obvious outward signs that I am being treated for cancer. I should be able to keep working, doing seminars, etc. as long as the status quo remains and that was one of my goals. (As long as I can tie my shoes, button my shirts, etc. we would continue treatment. Nuropathy would be expected to come on slowly and only become noticeable as time goes on. Anyway, it would be something we would be looking for.)

Now how did Dr. Lunin arrive at recommending this course of treatment? Well, I think Scott would be the first to say that we are in un-chartered waters. The fact of the matter is no one knows what will work for someone like me. In fact, we can't even say with certainty what caused my tumor to shrink...the radiation, the cisplatin/taxol regiment, or the two modalities in combination. In fact, from what I have gathered so far, it appears to me the treatments being used on lung cancer patients today have developed on a hit or miss basis (i.e. constantly trying different things to see what works). So, having said that, one could argue that there is no "right" answer and there is no "wrong" answer regarding the treatment regiment following definitive chemo radiation.

Here's what we do know. If I do nothing, it is very likely that I will, sooner or later, see a recurrence. How likely? Perhaps a 70% or 80% chance. f I do have a recurrence, I am not likely to survive it. Another way of saying it is I could do nothing and have a 20 - 30% chance of never see any cancer again....in fact my cancer may already be dead and gone and any further treatment might be unnecessary. The sad fact is that there is no way to know that for sure. We have to assume there are still some live cells floating around in my system and that I am in danger of recurrence. The goal, therefore, is to kill these other remnant cells (or keep them from reproducing) where ever they may be lingering using a systemic treatment.

We think the cisplatin/taxol doublet worked to kill my tumor, so why not just do more of the same at even higher dosages? The issue here is that my body can only take so much toxins before I begin to develop problems and too much exposure to the same chemical may make the cancer resistant; we might want to keep some of this ammunition dry for another fight down the road.

Scott's thinking in making the recommendation is why not treat me as though I had surgery to successfully remove the tumor? If you read the New England Journal Article, you will see that the regiment he proposes was tested on a population of early stage non-small cell lung cancer patients who had their tumors completely resected -- that is to say, the drug combination was tested on patients who had surgery to remove the cancer. There were a total of 482 patients in the study. On a random basis, half the patients were selected to receive the treatment and half did not. The median age of the patients in the study was 61 and the performance status (general health) was 0 or 1. (My performance rating is zero; i.e. general good health.)

What the study found was that overall survival was prolonged in the chemotherapy group in comparison to the observation group by about 20 months (94 vs. 73 months). Five year survival rates for patients with surgery and then the chemo regiment was 69%. The study found that vinorelbine plus cisplatin has an acceptable level of toxicity and prolonged disease free and and overall survival rates.

These statistics are significantly better than what I have been reading about tarceva and other consolidation drugs, where the "extended survival" was only one or two months -- hardly worth the trouble. Of course, we can't know exactly the role vinorelbine/cisplatin play in overall survival compared to surgery alone, but clearly it had a positive impact with relatively little downside. I think Scott's suggested course is about as elegant a solution as you are going to find in the circumstances.

Vinorelbine apparently interferes with cancer cell division; no one knows exactly why cisplatin works, but it seems to interfere with the DNA of cancer and causes the cells to die. So, I guess if you can kill whatever living cells are still in my system and keep these cells from reproducing, you are going to be better off. At least that is the hope.

There is a lot more to talk about...unfortunately, as usual, I am out of time. Tomorrow I have Rotary in the morning and a seminar in the evening. Maybe if I get back early enough from the seminar I can make another contribution.