Another Story-Breast Cancer

Few days back did a second opinion consultation. The husband and son had come with some reports.

The history started from May 2009. The lady had a lump in the right breast which was confirmed as malignant by Fine Needle Aspiration cytology (FNAC). The next report they had was a discharge summary from (HCG) Health Care Global Hospital, Bangalore which was dated October 2009. The discharge summary indicated a metastatic disease with metastasis in mediastinal lymph nodes, hilar lymph nodes and lung.

They did not mention what they did from May to October! My guess is that they would have taken either ayurvedic or homeopathic medicine and are now shy to tell about it.

She received 6 cycles of docetaxel+adriamycin+cyclophosphamide at HCG with partial response. Her ejection fraction had also dropped to 40. Possible a side effect of adriamycin. During the work up, they mention that, HCG missed getting estrogen, progesterone and Her 2 marker. After few chemotherapy the tests were done and she was found to be Her 2 positive and negative for hormonal receptors. But they did not add any trastuzumab or lapatinib.

As she had lump in her breast they consulted Dr.Raghavan. He started her on Lapatinib (Tykerb), Letrozole and Zoledronic acid (Zometa). Zometa was added prophylactically as she did not have bone metastases at that time, February 2010. According to their narration, Dr.Raghavan wanted them to take medicines directly from him and also get admitted for zoledronic acid administration. Zoledronic acid can be administered on an OPD (out patient) basis.

The good part was that PET scan done in September 2010 showed complete resolution of disease. There was no evidence of disease anywhere in the body.

The story gets murkier here. They did not have any reports post this and did not divulge any information regarding what medical decision was taken at that time. They mentioned that they took Tykerb for one more year but did not have any prescription for that period. It would have been a challenge to advice on the appropriate course of action in September 2010.

Fast forward to August 2013.

She has visited HCG again. She has local recurrence and now the disease has also spread to hilar lymph node, mediastinal lypmh node, lung, brain (right parietal and left temporal region), and also metastases in dorsal and lumbar spine. She is symptomatic for spinal metastases (she has pain). She is asymptomatic for brain metastases.

A new set of doctors have advised her gemcitabine+paclitaxel chemotherapy with pegfilgrastim support! They have mentioned that, if required, they will treat the brain metastases with Cyberknife!!

What did i counsel or suggest them?


Priority wise

1. Whole Brain Radiation 30Gy in ten fractions and RT to spine (involved areas)
2. Restart Tykerb, as it was taken 2 years back.
3. Consider Capectiabine oral chemotherapy.

I referred them to Dr.Vadiraj at Manipal or to Dr.Siddanna at Kidwai.

I am yet to hear from them...

Colon Cancer With Solitary Liver And Solitary Lung Metastases

One of my colon cancer patient, a 55 year old lady, is undergoing treatment for metastatic colon cancer.
Brief history:
In summer of 2008 she came to me post surgery. The tumor was extending to the serosa but the 9 nodes analyzed by the pathologist were negative for metastasis. In mofussil towns, the extent of surgery and pathology reporting are a suspect but i decided to give the benefit of doubt to the patient. For multiple reasons, which i intend to discuss some day, i treated her with 5 FU and Leucovorin which benefits 3.5% of people receiving it. FOLFOX 4 the competing regimen benefits 7.2% of people when the node is positive!

The lady tolerated the chemotherapy well and returned back to her normal life. Around 1 year 8 months later in December 2010 she presented with metastasis to liver and lung confirmed by biopsy and PET-CT. PET-CT was done in Mumbai. At the same time I move out of this mofussil town to a cosmopolitan city.

As the lady,  her husband and the referring surgeon wanted me to giver her treatment eventhough i was leaving the town and was going to be available only once a month, I was compelled to give her CAPOX, that is, capecitabine and oxaliplatin. After 6 cycles, with partial response, i switched to metronomic capectiabine therapy-flat 1000 mg per day. She tolerated this dose of capecitabine very well. With periodic Chest X ray and sonography of the abdomen, she continued her treatment. Her symptoms disappeared and she was/is like any other lady of her age.

On July 2012 it was reported on Chest X ray that the chest lesion had mildly increased in size.The liver lesion had reduced considerably in size. The lady and her husband were not willing for injectible medicines. For some reasons i did not push for Bevacizumab but hinted to them that they can visit their daughter in Mumbai and seek treatment there. They reiterated their trust in me and asked me to do the best i can. The lady was being monitored by telephonic calls and once in 2/3 month physical check up now.

At this juncture i added Thalidomide (phase 2 trial evidence) and Aspirin. She continued to take Capecitabine. Radiological investigation done in September 2012 indicated some objective response. I asked them to continue the same tablets. All this lead to excellent quality of life, good appetite, no symptoms or signs, and  the lady wished to know when she will be stopped of medication. Tough call! I kept pushing it.

Last week i reviewed her again. The liver lesion is not to be seen on USG (sonography). The lung lesion has increased in size. She is finishing her capecetabine this week and thalidomide in another few days.

I have said i will let them know about further treatment. My question/thoughts are

1. Advice them Bevacizumab therapy? {Cost, reluctance of patient?}

2.  Get PET-CT done and decide further treatment?

Surgery of both lung and liver metastases? {Emerging evidence, morbidity and also chance of surgical mortality. Why rock the boat?}

3. Enroll her in any trial? {Logistics, no study in India using new molecules like Regorafenib, most studies are with capecitabine}

4. Continue Aspirin and add Topotecan.

5. Hand her case to my partner and let him decide what is best for her. Make it very clear to the relative that I have done the best and that she will benefit more from dedicated care. {Question the role of mind, placebo etc effect of me!}

Will take some decision next week.

What is that i am aiming for this lady? Objective of treating her?

Aim for Quality of life or increasing her survival?  Both.

With metastases she has lived 27 months. I wish that she crosses 60 months milestone. The best will be that she wins this battle.