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  • Writer's pictureDr. Robert A. Nagourney, MD

For Advanced Cancer Patients – Never Say Never

Mesothelioma, a cancer that arises in the lining of the lung, affects approximately 3000 patients each year in the US. The disease affects men more than women, generally occurs in patients over 65, and is known to be associated with asbestos exposure. The overall five year survival rate is approximately 12%.

The combination of cisplatin plus Pemetrexed has become the standard of care for this disease, however this combination may not be optimal for everyone.

In 2006, I met a very nice 70-year-old woman with inoperable mesothelioma. We conducted a laboratory analysis and she went on to receive treatment with Cisplatin plus Pemetrexed treatment under the care of her physician. This, despite our laboratory finding that she was more sensitive to a different drug combination.

Unfortunately, her disease progressed. At this point, she returned to my care and we began treatment with the more active drug regimen. The patient responded immediately.

We were delighted with her good outcome, and she then returned to her original physician who adhered to our recommended combination. Year after year, she continued to respond but there was still evidence of low volume residual disease. With concern she might progress, she remained on a mild low-dose intermittent maintenance schedule.

When the patient moved to a new physician, he reviewed the many years of good response and suggested that she stop treatment in light of her very durable, 15 year, remission. With such a good and durable response, the question was how much is enough? I cautiously agreed that the patient could stop treatment, but insisted that she be closely followed.

The next PET scan revealed progressive disease associated with mild chest pain, and she restarted the low-dose chemotherapy that had proven so effective.

Several days ago, she stopped by the office to apprise us of her recent improvement and the good second response she has had to re-challenge with the same drug combination.

Her story offers several interesting insights.

  1. First, we know that advanced cancers are difficult to eradicate.

  2. Second and perhaps most importantly, one can live extremely well with cancer so long as the drugs are chosen rationally and administered carefully.

  3. Third, cancer is a field disease that arises in fertile tissue that provides malignancy-promoting inflammatory microenvironment

  4. Finally, “if it isn’t broken, don’t fix it”.

I explained that her disease represented one of two possibilities. One, I called the “mushroom hypothesis” where under certain conditions, she might continue to grow cancers (mushrooms) forever.

The second, I called the “spore hypothesis”, whereby cancer cells hunker down so deep into the tissue (soil) that we cannot eradicate them and they repopulate the tumor as soon as treatment is stopped.

Regardless of which may be correct, 16 years after her diagnosis she is well, active, spry and enjoying a full life. At 84 years of age and counting, we can call her a success.


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