Lung Cancer Success Story: Georgette (age 66)
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Patient Presentation: Squamous Cell Lung Cancer
Georgette is a 66-year-old woman from British Columbia, Canada, who’d been diagnosed with squamous cell carcinoma of the lung (SCLC). Although she’d smoked a pack of cigarettes per day for much of her life, she’d quit smoking many years ago.
Since her tumours were localized, her doctors decided to remove them via surgery. After surgery, Georgette was told that she was completely cured; no follow up was required. Her doctors told her that she’d soon be released from her local cancer agency, BCCA (British Columbia Cancer Agency) and her file there would be closed.
This seemingly good news was, in reality, quite disconcerting. You see, a few months after her surgery, Georgette had gotten a PET/CT scan. And this PET/CT scan had shown two potential tumours. Her doctors assured her this was most likely due to residual inflammation from her surgery.
But Georgette’s instinct told her she needed more information. She wasn’t ready to trust her life to guesswork, so she reached out to CTOAM for a second opinion.
Lung Cancer Success Story
How CTOAM Helped Georgette
First, we reviewed Georgette’s medical records and history. Georgette had very poor nutrition, so we created a healthy diet plan to reduce the growth of the cancer. We based this on human clinical trials and association studies that linked the intake of certain foods to the survival rates for her particular type of lung cancer.
Interestingly, our research found that both the intake and avoidance of specific foods often led to a reduction in the risk of SCLC and the progression of disease. Interestingly, the protective benefits of these foods was only found for lung cancers in smokers and ex-smokers.
We then obtained a sample of Georgette’s tumour tissue and sent it for tumour DNA sequencing. We looked for cancer-causing mutations in the DNA of over 340 genes involved in lung and other cancers.
The results from Georgette’s tumour DNA sequencing showed that she had an EGFR L858R mutation. This mutation is a negative prognostic feature and patients with this mutation have minimal response to standard chemotherapy.
However, this mutation allows for the use of EGFR targeting drugs, such as tarceva. Patients that receive EGFR targeted drugs such as tarceva live about two to three times longer than patients receiving standard chemotherapy. And because this is a targeted drug, it also has minimal side effects.
We immediately wrote up a patient report for Georgette’s public healthcare treatment team urging them to put her on this life-saving drug.
Unfortunately, her doctors told her that this drug was not approved for her type and stage of lung cancer: they would not be able to prescribe it for her until she was palliative and had advanced stage IV cancer.
We then asked her to contact an independent community oncologist near her home town (whom CTOAM had prior experience working with). Georgette’s community oncologist was able to prescribe tarceva for her. Significantly, he was also able to get her healthcare plan to cover the cost of the drug.
Our cancer experts needed a) to know the current status of her cancer and b) a way to measure the benefits of the tarceva. To achieve both, we performed a liquid biopsy to detect the level of her EGFR mutation prior to her treatment.
- What is a liquid biopsy? This liquid biopsy detects circulating tumour DNA (ctDNA). It also measures the ratio of the mutated EGFR to the non-mutated EGFR genes. This provides us with a rough idea of the actual amount of cancer cells in her body at a given time.
Since Georgette’s EGFR mutation was unique to her tumour cells, we could measure the amount of the EGFR mutation prior to and during her therapy. This would give us an idea of the relative amount of tumour cells in her body. If the treatment worked, we would see a significant decrease in the percentage of the EGFR mutation from a sample of her blood.
Testing all of the body’s tumours at the same time using liquid biopsies is a much more accurate way of determining responses to EGFR inhibitors than other standard methods. (The public medical system often uses radiographic imaging and other non-specific blood-based tumour markers, such as CEA and 19-9.) Plus, liquid biopsies remove the need for patients to be subjected to ionizing radiation (as with CT and PET/CT scans).
Looking at a complete body-wide, drug-induced, anti-tumour response is essential for determining how well the treatment is working.
Prior to her treatment, Georgette’s EGFR levels were undetectable.
During the course of her treatment, a government funded PET/CT scan showed that there were still two remaining suspicious growths in her lungs.
How to Detect Lung Cancer
What is a PET/CT Scan?
PET/CT, unlike other forms of medical imaging, is able to identify active tumours at a very small size, based on the biological activity of the tumour.
While most forms of imaging look at the density of the tumour and compare it to the surrounding tissues, PET/CT uses a harmless radioactive isotope that is bound to a sugar molecule.
Since tumour cells are constantly growing and therefore highly metabolic, they drink up more of the sugar-isotope solution than the surrounding tissues and any tumours will glow like Christmas tree lights.
Importantly, since only live tumours will drink the sugar-isotope solution, PET/CT can tell if a tumour is alive or if it has been affected (killed) by a specific treatment. No other form of imaging can reveal this essential information!
Furthermore, since the amount of the sugar-isotope solution a specific tumour drinks depends on how fast it is growing, a PET/CT can determine how aggressive a specific tumour is compared with other tumours in the body. This is referred to as the serum uptake value (SUV), and allows doctors to focus on the tumours that are most likely to metastasize.
Unfortunately, Georgette’s PET/CT showed sites of very low SUV activity: while this could be indicative of a tumour, it was not conclusive.
So we performed another ctDNA liquid biopsy, which also came back as negative. This indicated that the PET/CT was most likely based on inflammation from her previous operation.
While Georgette remains stable on tarceva, recent studies identified that another EGFR targeting drug (afatinib) was actually superior to the tarceva. Better yet, afatinib was available at her local cancer agency.
Lung Cancer Treatment
What is Afatinib?
CTOAM’s research uncovered the following data. It ultimately shows that afatinib can increase the chance of progression-free survival, as well as improve overall quality of life, in SCLC patients:
- Reduced risk of progression: Afatinib irreversibly binds to both EGFR and HER2. Compare this to tarceva, which is just a reversible inhibitor that only binds to EGFR. This is important because dysregulation of ErbB receptors (such as HER2) play a role in SCLC progression.
- Beneficial as initial treatment: Afatinib given as the initial treatment significantly reduces the risk of progression by 27% compared to gefitinib. Furthermore, these improvements in PFS were found to be more pronounced over time: a significantly higher proportion of patients were alive and progression-free at 18 months (27% versus 15%; P = 0.018) and 24 months (18% versus 8%; P = 0.018), when compared to other EGFR inhibitors.
- Beneficial as second line treatment: Afatinib offers significant benefits as a second line treatment in patients with SCLC that had progressed while taking tarceva. In these patients, treatment with afatinib reduced the risk of cancer progression by 19%, and reduced the risk of death by 19% compared to tarceva.
- Improved quality of life: Importantly, further research confirmed afatinib was also associated with improvements in patient reported outcomes. Studies showed that more patients had improved overall health-related quality-of-life (36% versus 28%; p=0.041), reduced cough (43% versus 35%; p=0.029), and reduced shortness of breath (51% versus 44%; p=0.061) with afatinib than with erlotinib.
In other words, regardless of whether afatinib was given as the initial treatment or given after the patient received tarceva, the benefits were significant and the overall health and well-being of the patient was improved.
6. Patient Outcome
Currently, Georgette is still cancer-free and taking tarceva almost three years since her initial diagnosis. Unfortunately, BCCA will not provide Georgette with the new and improved EGFR inhibitor afatinib unless her disease progresses. However, she can pay out of pocket if she so chooses.
Furthermore, when tarceva and/or afatinib stop working, she has a variety of other targeted therapies that have the potential of providing her with more time – without the damaging side effects of standard chemotherapy.
Further Updates on Georgette’s Outcome
2017 June 27th Update
Currently, Georgette is feeling very well. Her oncologist recently assured her and her loved ones that she is still cancer-free, since both her PET/CT and tumour markers remain negative. Further, she’s been able to reduce the dose of tarceva: she now alternates between taking 100mgs and 50mgs daily. This helps to reduce the side effects of the drug, as well as the overall cost.
As you can see, CTOAM’s advanced diagnostics, records review, and consultations can result in significant benefits to a patient’s outcome. Having access to a team of precision oncology specialists, doctors, and patient advocates can make all the difference in the outcome of your disease.
If you or a loved one has cancer, contact us today so we can do a brief review of your medical records. CTOAM’s cancer experts will ensure that you have access to the most advanced tests and treatments available for your unique form of cancer – as close to home as possible.
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