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Palliative vs. Curative Intent
I'm thinking a lot about this topic because of my own story. I am Stage IV and was that way at diagnosis. After over three years of metastases in my lower lungs slowly getting larger and causing more trouble for me, the cancer in my right lung finally caused a trip to the ER. It was blocking the airway, and I ended up with pneumonia (in June). I've been on three rounds of antibiotics since then. I have been asking or wondering about local treatment for my lung mets for at least 2 years. Last October a scan showed no detectable cancer in my body except in the lungs, and that was getting better. Last January there was still no detectable cancer anywhere but my lungs, but they were lighting up more.
Fast forward to this August. My medical oncologist referred me to radiation oncology, and I'm halfway through a 12-round course of radiation to my right lung, to correct the cause of the pneumonia and hopefully eradicate the cancer. The radiation folks said if it goes well in my right lung they can do the same thing in the left lung later.
It occurred to me that if radiotherapy is a good idea now, it would have been an even better idea 9 months ago, when I was younger and not battling a chronic bacterial infection. I saw my NP today and asked her about that, trying not to sound critical, but just wanting to know. She asked the onc and came back to report that the reason for waiting is "We can't radiate everything."
I don't really consider that an answer. At that time chemo (Abraxane, Herceptin, & Perjeta) had been effective for everything but the lung tumors. I think that would have been a perfect time to go to a targeted treatment. Of course you "can't radiate everything." But my only "thing" at the time was the cancer in my lower lung lobes.
The folks in radiation oncology explained that for various reasons lung tumors are hard to control with chemo. They know how to handle them with radiation. They told me there are studies showing good results for patients like me who are on the same treatment plan as I. Other cancer centers have gotten measurable benefits from using local treatment on metastases of all kinds.
I think it comes down to how one defines "palliative intent." I seem to have a more robust, proactive view of it than my oncologist does. I don't think I should have had to get sick before she recommended a new treatment modality for my chemo-resistant lung mets.
I think "palliative" means "do all you can, within reason, and consistent with maintaining quality of life, to control the disease and keep the patient as healthy and functional as possible." I don't know how she sees it. I just see a very large amount of territory between "we can't radiate everything" and what happened to me.
I can't go someplace else because here in the Wild West my cancer center is basically the only game in a gigantic geographical area. When I was in Boston I had tons of choices. Here I actually tried to get a second opinion, and the people at the other doctor's office were so inept and unhelpful about getting together my medical records in advance of the appointment that I gave up and canceled it.
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Amy
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4/19/11 Diagnosed invasive ductal carcinoma in left breast; 2.3 cm tumor, 1 axillary lymph node, weakly ER+, HER2+++
4/29/11 CT scan shows suspicious lesions on liver and lungs
5/17/11 liver biopsy
5/24/11 liver met confirmed--Stage IV at diagnosis
5/27/11 Begin weekly Taxol & Herceptin for 3 months (standard of care at the time of my DX)
7/18/11 Switch to weekly Abraxane & Herceptin due to Taxol allergy
8/29/11 CT scan shows no new lesions & old lesions shrinking
9/27/11 Finish Abraxane. Start Herceptin every 3 weeks. Begin taking Arimidex
10/17/11--Brain MRI--No Brain mets
12/5/11 PET scan--Almost NED
5/15/12 PET scan shows progression-breast/chest/spine (one vertebra)
5/22/12 Stop taking Arimidex; stay on Herceptin
6/11/12 Started Tykerb and Herceptin on clinical trial (w/no chemo)
9/24/12 CT scan--No new mets. Everything stable.
3/11/13 CT Scan--two small new possible mets and odd looking area in left lung getting larger.
4/2/13--Biopsy of suspicious area in lower left lung. Mets to lung confirmed.
4/30/13 Begin Kadcyla/TDM-1
8/16/13 PET scan "mixed," with some areas of increased uptake, but also some definite improvement, so I'll stay on TDM-1/Kadcyla.
11/11/13 Finally get hormone receptor results from lung biopsy of 4/2/13. My cancer is no longer ER positive.
11/13/13 PET scan mixed results again. We're calling it "stable." Problems breathing on exertion.
2/18/14 PET scan shows a new lesion and newly active lymph node in chest, other progression. Bye bye TDM-1.
2/28/14 Begin Herceptin/Perjeta every 3 weeks.
6/8/14 PET "mixed," with no new lesions, and everything but lower lungs improving. My breathing is better.
8/18/14 PET "mixed" again. Upper lungs & one spine met stable, lower lungs less FDG avid, original tumor more avid, one lymph node in mediastinum more avid.
9/1/14 Begin taking Xeloda one week on, one week off. Will also stay on Herceptin and Perjeta every three weeks.
12/11/14 PET Scan--no new lesions, and everything looks better than it did.
3/20/15 PET Scan--no new lesions, but lower lung lesions larger and a bit more avid.
4/13/15 Increasing Xeloda dose to 10 days on, one week off.
7/1/15 Scan "mixed" again, but suggests continuing progression. Stop Xeloda. Substitute Abraxane every 3 weeks starting 7/13.
10/28/15 PET scan shows dramatic improvement everywhere. All lesions except lower lungs have resolved; lower lungs noticeably improved.
12/18/15 Last Abraxane. Continue on Herceptin and Perjeta alone beginning 1/8/16.
1/27/16 PET scan shows cancer is stable.
5/11/16 PET scan shows uptake in some areas that were resolved on the last two scans.
6/3/16 Begin Kadcyla and Tykerb combination
6/5 - 6/23 Horrible diarrhea from K&T together. Got pneumonia.
7/15/16 Begin Kadcyla only every 3 weeks.
9/6/16 Begin radiation therapy on right lung lesion that caused the pneumonia.
10/3/16 Last of 12 radiation treatments to right lung.
11/4/16 Huffing and puffing, low O2, high heart rate, on tiniest bit of exertion. Diagnosed as radiation pneumonitis. Treated with Prednisone.
11/11/16 PET scan shows significant improvement to radiated part of right lung BUT a bunch of new lung lesions, and the bone met is getting worse.
11/22/16 Begin Eribulin and Herceptin. H every 3 weeks. E two weeks on, one week off.
3/6/17 Scan shows progression in lungs. Bone met a little better.
3/23/17 Lung biopsy. Tumor sampled is ER-, PR+ (5%), HER2+++. Getting Herceptin and Perjeta as a maintenance treatment.
5/31/17 Port placement
6/1/17 Start Navelbine & Tykerb
Last edited by Mtngrl; 09-16-2016 at 06:15 PM..
Reason: To align my faulty recollection of dates with the more reliable ones in my signature
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