What are the treatment options for my mother’s lung cancer?

Question

Hello doctor,

My mom is 62 and has EGFR-positive non-small cell lung cancer that has spread to her brain and spinal cord lining. She was on Erlotinib, then switched to Osimertinib after the leptomeningeal spread. She did proton radiation to the whole brain and spine, Osimertinib got bumped to 160 mg, and her symptoms improved for a while. They eventually tapered her off Dexamethasone completely, but she got really bad, bedbound, barely alert, severely weak, and nauseated and could only eat pureed food.

About nine days ago, they restarted Dexamethasone at 8 mg for two days, then dropped to 4 mg daily. Since then, she has been more alert, eating a bit more, less nauseated, and less tired. Her last MRI showed the disease is largely stable, with maybe some improvement in the spinal spread. She also got compression fractures at L1-L3 during PT and started Denosumab. Where do things stand?

Kindly help.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

She has leptomeningeal disease (LMD) that kept progressing despite Osimertinib 160 milligrams and proton craniospinal radiation. Leptomeningeal disease is cancer spread to the surrounding brain and spinal cord, causing neurological deficits, severe weakness, pain, motor loss, nausea, fatigue, and reduced functional independence.

The Dexamethasone brought her alertness and nausea back, and that is a real improvement day to day, but it is the steroid reducing inflammation, not the cancer retreating. The magnetic resonance imaging (MRI) showing stable to slightly better spinal leptomeningeal disease (LMD) is something, but she is still bedbound with severe motor deficits, and that level of functional loss with this much leptomeningeal involvement is very difficult to reverse.

The L1-L3 compression fractures are adding to her pain and weakness on top of everything else. Denosumab covers the bone protection side of that. She is still on Osimertinib, and given her epidermal growth factor receptor (EGFR) L858R status, there is no reason to stop it right now. The steroid taper will need to be handled carefully since she responded so clearly to restarting it.

If a goals-of-care conversation has not happened yet, it really needs to. Her oncologist and palliative care team should be on the same page with the family about what she wants, given where things are.

I hope you are satisfied with my answer. For further queries, you can consult me at iCliniq.

Thank you.