My dad is diagnosed with stage 4 non-small cell lung adenocarcinoma. Kindly suggest treatment options.

Question

Hello doctor,

I want to get a second opinion on my father's treatment for advanced non-small cell lung adenocarcinoma. I want to ensure he is given the best possibility for the longest survival with good quality of life.

He started suffering headaches and was also bringing up small specks of blood in sputum. He went to his GP, who just put him on antibiotics and thought might be sinus problems he has had for a long time. After a few weeks, with headaches getting worse and nausea and vomiting, he saw another GP, and tests were scheduled. He has had CT scans, PET scans, MRI. There is a lesion in his left lung upper lobe. There is low attenuation (3.5 x 2 cm) in the right frontal lobe anteriorly and a lytic lesion in the left proximal femur. He was a pipe smoker for many years but has now given up. He had no cough and still does not, no wheezing, and oxygen saturation was 97%. ECG was normal, and he was a fit and active 67-year-old, regularly windsurfing and cycling.

He has now been told he has stage 4 cancer, not curable and basically just a case of keeping him going as long as possible. To that end, the currently prescribed treatment are Dexamethasone to relieve pressure in the brain and alleviate headaches, Folic acid, Levomepromazine, Lansoprazole 30 mg for gastro-reflux, and Oral morphine for pain in the head.

He will then start chemotherapy in two weeks. One day every three weeks to be hooked up to a drip for several hours for four to six rounds. I would like to know if this is the best treatment as I would have expected radiotherapy for the brain lesion or had considered trying to get him cyberknife treatment for that. However, the consultant does not seem to be interested in pursuing these options and says there is no point.

We have also not been given any idea of chances of success in keeping cancer at bay, or if it is possible for it to go into remission and survival predictions. Although he was told he should start thinking of where he would like to die - hospital or home. Please help.

Answer 1

Hello,

Welcome to icliniq.com.

Your father is suffering from non-small cell lung carcinoma, stage IV. The disease subtype is adenocarcinoma.

Since it is a stage IV adenocarcinoma and his age is already 67, I would advise you on EGFR (epidermal growth factor receptor) and ALK (anaplastic lymphoma kinase) mutation investigation from his biopsy sample. If this mutation report is positive (i.e., the EGFR mutation is positive), then oral Tyrosine kinase inhibitor (TKI) tablets, such as the oral chemotherapy tablet Erlotinib, will work for him and alleviate some of his suffering.

If the ALK mutation is positive, then an oral chemo tablet called Crizotinib will work. Side effects of oral chemo tablets are only skin rash and diarrhea.

If mutation tests are negative, injectable chemotherapy called Pemetrexed could be an option; if mutation tests are positive, oral TKI chemo tablets are the first option.

Since it is already stage IV and his age is 67 years, the intent of treatment is palliation and improving quality of life, and not a cure. Dexamethasone to relieve pressure on the brain, Morphine for headache, and Lansoprazole can be continued. I will also advise radiation to the brain lesions, which will help him improve his quality of life.

I hope this helps.