Second opinion from Stanford

We saw Dr. Heather Wakelee at Stanford on March 31 for second opinion.  We were impressed by her knowledge and experience.  She has been specializing in thoracic oncology for 10 years at Stanford, and now is the director of the group.  One can tell that she is a scientist and her answers are based on published clinical studies.  The consultation lasted for 1 hour 45 minutes including the time interfacing with her interns.

Her recommendations and comments:

1. Four cycle chemo is a standard in treating lung cancer, but no one knows how effective it is versus 2 or 3 cycles, because there has never been clinical studies done on this. Hence,the decision is usually based on how the disease respond to the chemo after 2 cycles and how much the patient can tolerate the chemo.  However, at the same time, the effectiveness of the first 2 cycles does not predict the effectiveness of the next two.
2. From the PET scan, the tumors were reduced by about x% after two cycles, but it is difficult to judge the effects on the small dots in both lungs.  A CT scan can tell better.  
3. Cisplatin is toxic and will have late effects on the nerves (which means long term side effects that develop later).  In Dad's case, she said we can go without the Cisplatin in the fourth cycle if we are concerned.
4. The standard treatment for EGFR mutation like Dad has is Tarceva first.  Treatment starting with chemo is usually for patients who have no EGFR mutations.  However, the overall survival is the same for either route.  No one can say one is better than the other.  
5. There is no clinical study shows that starting with chemo may prolong the effectiveness of Tarceva.
6. Most patients can tolerate Tarceva, but some patients found it as bad as the chemo.  The most common side effect is facial rashes.
7. Since we have already taken the chemo first route, we should try, after the fourth cycle, to continue the chemo without the Cisplatin, i.e. Alimta and Avastin for as long as we can before switching to Tarceva.  The reasons are
   - Try to get the most out of the chemo and save Tarceva for later
   - Insurance most likely will not pay for Avastin after we stop, because Avastin is expensive, $15,000 per infusion.  
8. Tarceva does not work forever, but there will be other steps that we can take after Tarceva.  
9. Her research focus is on how to make Tarceva works longer on the patients.  
10. One of the clinical trials she is conducting is Tarceva plus immune therapy.  She asked us to consider it before taking Tarceva.  The clinical trial is only open to patients who have not taken Tarceva.  If Dad starts taking Tarceva, he will not be eligible.  (will write about her clinical trial in another blog)
11. We should do CT scan instead of PET scan for the next few check points because PET scan gives more radiation to the body.  Dad already had two in one month.  CT scan every 2 to 3 months is sufficient.  Also, CT scan is lower risk to the health and will provide a better images for measuring and determining if the tumors have reduced.  Only do PET scan when there is suspicion that the tumors may have spread.
12. LingZi and JinShen will not interfere with the chemo based on the research done in Hong Kong

Stanford will send a note to Dr. Dormady about her recommendation.  We will see what Dr. Dormady has to say.