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弟弟IV期低分化肺鳞癌,8个月又13天,11月19日离世。年轻的他,其实从未离去!

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发表于 2012-5-29 11:20:42 | 显示全部楼层 来自: 中国江苏苏州

RE: 弟弟的抗癌记录:低分化肺腺鳞癌,纵膈多发淋巴结和左股骨转移

cloudlb 发表于 2012-5-28 13:51
行动矮人和请带我去阿尔科两位:你们的治疗思路都很清晰,选择的都是最正确与合适的治疗方法。祝福你们和你 ...

谢谢你,大家一起努力吧
有爱,就有奇迹!
 楼主| 发表于 2012-6-1 04:02:06 | 显示全部楼层 来自: 美国
自我解惑

半个月前,就弟弟下一步的治疗,我们感到困惑。经过更多的调研,我有了答案,写在下面:

Q:四个周期化疗完成后,如果有效,是否还要再化疗两个周期?
A:如果评估有效或稳定,只要弟弟耐受的住,并且主治医建议,我们支持弟弟用原方案(GP)再化疗两个周期。万一他耐受不了顺铂的副作用(肠胃反应和肾毒性),且主治医同意,我们支持弟弟用健择单药完成这两个周期的化疗。

我看了不少小细胞中晚期肺癌患者生存3年以上的治疗经过,主要是化放疗,并且强调首次化疗要足量。我觉得弟弟应该用小细胞肺癌的治疗理念,首次化疗要尽量做足。弟弟虽然是非小细胞肺癌,但他的癌是低分化的,很顽固,很容易复发。事实上,他的分化低到了很难辨别是鳞?是腺?还是腺鳞?为此,我们曾耗了不少精力:301医院病理科诊断是肺腺癌;中国医科院肿瘤医院我们找了不同的病理专家,有说肺鳞癌,有说肺腺鳞癌;北京协和医院认为以鳞为主,少量的腺;北京肿瘤医院则干脆说:低分化非小细胞肺癌,看不清是鳞还是腺!

最初,我们很纠结。在我读了Dr West的文章:"低分化非小细胞肺癌的困境"后,就释然了。
(The Predicament of Poorly Differentiated NSCLC/NSCLC NOS
http://cancergrace.org/lung/2010 ... entiated-nsclc-nos/
他指出,有些非小细胞肺癌由于分化太低,即使用最先进的方法也很难辨别是鳞还是腺。

Q:4-6个周期的化疗结束后,是否要接着做维持治疗--靶向治疗?
A:准备除主治医外,多问诊几个肿瘤内科的专家(包括医科院肿瘤医院的李峻岭教授),听取他们的建议。只要他们给我们这个选择,我们倾向于接着做维持治疗,用"特罗凯",但6个化疗与用特罗凯之间可能会休息20天。弟弟没有EGFR突变,并且曾多年吸烟。

Q:4-6个周期的化疗结束后,是否要接受胸部放疗?
A:6个周期的化疗结束后,准备找放射科专家会诊,看是否有胸部放疗指征?倾向于不做。因为弟弟对侧纵膈和左肺门淋巴都有转移。似乎太冒险了?

对此,朋友们若有不同意见,请指教。万分感谢!

另外,4个化疗后,弟弟的白细胞下降不少,打算加"日达仙"。
6月4日,他的4个化疗评估会出来,愿上帝保佑结果是好的。弟弟和我们大家都太需要这种鼓励了!
有爱,就有奇迹!
发表于 2012-6-2 07:57:35 | 显示全部楼层 来自: 中国江苏苏州
我的主治医生告诉我,3B治愈不复发是15%,方案是紫杉醇+卡铂同步放化疗,比较伤身,我决定去拼一次,
有爱,就有奇迹!
 楼主| 发表于 2012-6-2 08:19:02 | 显示全部楼层 来自: 美国
本帖最后由 行动矮人 于 2012-6-2 09:38 编辑
请带我去阿尔科 发表于 2012-6-2 07:57
我的主治医生告诉我,3B治愈不复发是15%,方案是紫杉醇+卡铂同步放化疗,比较伤身,我决定去拼一次,


请带我去阿尔科,祝福你!或许你想问一下你的主治医,是否"卡铂 + 紫杉醇 + 阿瓦斯丁"更好?

我访问到一位低分化肺腺鳞癌3B的病友,6年前确诊后,先做了5个GP(健择+顺铂)化疗,之后又做了35次胸部放疗;还有中医扶正,多年坚持郭林新气功。治愈了。至今,从没有复发,没有转移过。不过,因放疗,导致他的左肺纤维化。

我弟弟若没有骨转移和锁骨淋巴转移,我可能会支持他放疗。
有爱,就有奇迹!
 楼主| 发表于 2012-6-2 09:05:10 | 显示全部楼层 来自: 美国
本帖最后由 行动矮人 于 2012-6-2 09:59 编辑

一篇值得阅读的文章

Do We Exhaust the Benefit of a Chemo After Four Cycles of First Line Chemo for Advanced NSCLC?

Published December 24, 2011, By Dr West

One of the longstanding ideas in lung cancer management is that you exhaust the benefit of first line combination chemotherapy after 4-6 cycles of treatment.  This is based on a few trials that showed no survival benefit for treating beyond that point, as summarized in this early post I wrote all the way back in my first few months of doing this (OncTalk days, pre-GRACE). This standard of care is based in part on the premise that the incremental adverse effects may escalate faster than any incremental benefit for a platinum-based doublet.  With cisplatin, cumulative nausea, fatigue, risk of significant kidney damage, neurotoxicity, and overall “platinum blues” tend to make treatment beyond 6 cycles infeasible and disproportionate to any potential added benefits of ongoing therapy.  With carboplatin, cumulative cytopenias (low blood cell counts) and a rapidly escalating risk of a severe and potentially dangerous hypersensitivity reaction (which can also occur with ongoing cisplatin but is notorious and almost inevitable with carboplatin) make indefinite carboplatin too challenging and inadvisable.

In the last few years, the concept of maintenance therapy for patients who haven’t experienced progression or prohibitive side effects after 4-6 cycles of first line combination chemotherapy has taken hold.  Initially, this default strategy was baked into the development of Avastin (bevacizumab, 贝伐单抗): the trial that led to approval of Avastin gave six cycles of carbo/Taxol (paclitaxel)/Avastin(卡铂 + 紫杉醇 + 阿瓦斯丁), followed by maintenance Avastin.  It showed a survival benefit for the whole program, but it was not possible to say whether the benefit was from the addition of Avastin with chemo, from the maintenance Avastin, or both components.

Meanwhile, many trials over the last few years have shown a clear improvement in progression-free survival (PFS) and a suggestion of improvement in overall survival (OS) with addition of switch maintenance therapy, where a new treatment is initiated after 4-6 cycles of first line combination chemotherapy is completed in non-progressing patients. This work is discussed in more detail elsewhere and led to a general standard of at least considering maintenance therapy in this setting for appropriate patients, even if the data supporting a survival benefit are flawed enough to leave most experts considering maintenance therapy far from a mandate.

So now let’s turn to the question of whether there might be a value in continuation maintenance therapy, where one or more of the agents from the first several cycles of treatment is continued as a maintenance therapy until progression, following the discontinuation of one or more agents from first line therapy.  At this point, I would say that we now have a good amount of compelling evidence that 1) there is clear evidence that patients who benefit from the first four (or potentially more) cycles of first line therapy can benefit from continuing it on an ongoing basis, and 2) the magnitude of benefit appears to be very comparable, if not superior, to “switch” maintenance therapy.   It depends on the individual patients, but it’s clear that the benefit of some agents is not exhausted after four cycles in certain patients.  Let’s take a closer look at the evidence.

First is the “TORCH” study done primarily in France by Perol and colleagues, which I covered rather exhaustively in a prior post.   This trial gave cisplatin(顺铂)and gemcitabine(吉西他滨)for four cycles to all patients, then randomized non-progressing patients to either maintenance gemcitabine (continuation maintenance therapy), Tarceva (erlotinib,  特罗凯) (switch maintenance therapy), or observation; all patients were then started on Alimta(力比泰)at the time that progression was detected.  Both gemcitabine and Tarceva were associated with an improvement in PFS and a non-significant, slight trend toward improved OS compared with no maintenance therapy; while the trial wasn’t designed to compare the maintenance strategies to each other, gemcitabine appears numerically (and I would argue convincingly) more impressive in every measurement. In particular, patients who had an objective response (complete or partial response) to first line chemo with cisplatin/gemcitabine were especially likely to benefit from maintenance gemcitabine. While Tarceva is FDA-approved and used pretty commonly as a maintenance therapy now, no company has a financial incentive to advocate maintenance gemcitabine… so nobody really talks about maintenance gemcitabine.

More recently, we’ve seen data from the PARAMOUNT trial (covered well in Dr. Nasser Hanna’s podcast on Highlights in Lung Cancer from ASCO 2011), done in Europe and randomizing patients after four cycles of cisplatin/Alimta (pemetrexed, 培美曲塞) to maintenance Alimta or placebo.  This reported a very clear and highly statistically significant PFS benefit with Alimta, while OS wasn’t reported at ASCO.  As in the TORCH study, the patients who demonstrated significant tumor shrinkage from the first line combination had the greatest benefit from additional Alimta chemotherapy.

Finally, I recently covered the results from the European AVAPERL study that randomized patients who hadn’t progressed after four cycles of cisplatin/Alimta/Avastin(顺铂 + 力比泰 + 阿瓦斯丁)to either maintenance Alimta/Avastin or Avastin alone– two different versions of continuation maintenance therapy.  This trial showed an overwhelming and statistically significant benefit in PFS for the Alimta/Avastin combination, along with a trend favoring the combination for OS.   And the actual numbers in this trial look excellent — some of the best results that we’ve ever seen in advanced NSCLC.   This trial strongly supports the benefit of further Alimta and calls into question the real value of maintenance Avastin as a single agent for advanced NSCLC.

Putting all of these results together, it’s clear to me that continuation maintenance therapy can be every bit as effective as switch maintenance therapy, and therefore, there is still potential benefit in further therapy for an agent beyond 4-6 initial cycles. In addition, patients who have benefited most from an agent as first line therapy are the ones most likely to still benefit from more of it.

In my mind, the challenge is that there are certain agents that don’t lend themselves well to ongoing therapy: the platinums(铂类), for the reasons I mentioned above, Taxol(紫杉醇)for its high probability of significant neuropathy(神经毒性), and perhaps also Taxotere-泰索帝 (docetaxel, 多西紫杉醇) for cumulative fatigue and low blood counts.  But overall, these studies indicate that for the agents that can be administered and well tolerated for a prolonged period of time, the value isn’t exhausted after a few months and can provide meaningful benefit for patients who haven’t progressed on them, especially those who showed tumor shrinkage from them.

http://cancergrace.org/lung/2011/12/24/beyond-4-cycles-1st-line/
有爱,就有奇迹!
发表于 2012-6-2 22:45:42 | 显示全部楼层 来自: 中国江苏苏州
我的方案是浙江权威,在国内也有一定权威的专家定的,我想应该是最好的方案了,我不怎么懂,还是不干涉了
有爱,就有奇迹!
发表于 2012-6-5 12:21:12 | 显示全部楼层 来自: 中国山东青岛
记录真的很详细,方案选择也很科学。
期待奇迹。
有爱,就有奇迹!
 楼主| 发表于 2012-6-6 01:30:01 | 显示全部楼层 来自: 美国
都是花菜 发表于 2012-6-5 12:21
记录真的很详细,方案选择也很科学。
期待奇迹。

谢谢你,都是花菜。我们一起努力,创造奇迹!
有爱,就有奇迹!
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