Chemotherapy before or after surgery
Hi, I am new here. My father was recently diagnosed with NSCLC. It’s at least stage 2b. We have seen two oncologists in Northern Virginia. One suggested to have surgery now and do systemic treatment after. The other oncologist suggested chemo and immunotherapy before the surgery. Given my dad is 80 and qualify of life is most important factor to concern, I am thinking to go with surgery first. I am scared that I will lose him and also scared that I am making wrong decision for him. Any help please? Thank you!
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Not to muddy the waters more but I would discuss neoadjuvant or adjuvant immunotherapy with stereotactic body radiotherapy instead of surgery. Not quite as effective as surgery but a heck of a lot easier.
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Thank you so much for the reply! We did talk to radiologist about SBRT and Proton therapy. Unfortunately my dad has one positive lymph node near the mass, so any radiation therapy need to combine with Chemotherapy. Doctors said immunotherapy need to go with chemo too, and no target therapy for him. I researched and found even among healthy young patients, the rate to have grade 3 or above chemo related adverse effects will be 40-50%. That’s really high in my opinion. It seems no guidance of systematic treatment for older patients yet. Hope his surgery goes well!
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Do you know his PD-L1 or tumor mutation burden numbers?
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For some reason, his biopsy results do not show PD-L1 level. I asked his surgeon and I was told that particular result takes time. I am wondering maybe doctor didn’t order this test when doing his biopsy. His surgeon promised PD-L1 will be analyzed from his surgery results.
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Yeah that should be know before doing anything. If he had 100% PD-L1 he could quite easily get away with immunotherapy only which I've done over 4 years for stage 4b
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Wow! That’s very encouraging! Thanks for sharing the information. I guess it’s too late to ask his pulmonologist to order PD-L1 test now since the biopsy was done almost 3 weeks ago. Just hope his surgeon won’t miss this important test. Where can I find survivors network who are treated by the same doctors/facilities to share experiences? I feel that would be very helpful.
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It can takesl about 4 weeks for all the genetic testing to come back. Check with the cancer center for local support groups.
https://m.facebook.com/groups/986284055480932/
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Thank you so much!
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How much do you know about the side effects of immunotherapy? I began my lung treatments with chemo immunotherapy in October of 2023. In May of 2024, I was hospitalized with pneumonia. I am 68 years old and I had much difficulty overcoming the pneumonia. Prior to pneumonia and other complications from it, I had never been on oxygen. After pneumonia and as of this date, I began and am still using oxygen. After pneumonia, I had to regain strength for walking and to learn to use a walker. After my bout with pneumonia, I learned that immunotherapy can and does cause pneumonia in some cases. As I said, I am 68. You said your father is 80. Make sure that you know everything there is to know about immunotherapy and how it may affect your father's quality of life if this is the route that you choose to go for him.
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Many thanks for sharing your experience with chemo immunotherapy. I hope you are recovered from pneumonia and no longer need to use walker or oxygen. My father had the surgery on December. Chemotherapy plus immunotherapy is a standard treatment for NSCLC after surgery. But we are thinking not doing any further treatment. His PD-L1 level is low, 1%, so immunotherapy may not work well on his case. Considering all the side effects, I think it’s not worth it to using chemo immunotherapy on him. Good luck on yours everything! Wishing you a healthy, happy new year!
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Hopefully your dad is recovering well. Does he have a palliative or geriatric specialist as part of his cancer team? Do they offer integrative oncology at his center? Some centers offer it as part of their standard treatments for cancer. Unfortunately It's not generally covered by Medicare though. But again many parts are covered for free at major treatment centers.
Good luck to you guys.1 -
I have never heard or think about the palliative care. Now after you mentioned it, I googled and found his cancer center does provide this service. I will ask his care team next time. Thank you so much for the information! Yes, my dad is recovered very well. Not having further treatment is the idea from his medical oncologist, I am still debating whether to take this suggestion. I am changing mind every day.
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My father’s cancer spread to lumbar, he has to start chemotherapy and immunotherapy now. I am so shocked. It happens so fast from stage II or stage IV now. Before the surgery on Dec 2024, he can still do Latin dance, after the surgery he recovers so well and can play pool table and walk one hour per day. But now just one month after he is fatigue and lose appetite. I am so scared that I will lose him very soon. I want him has no pain at the end the life. Doctor said I think too much, it’s not the time yet. Am I? What should I do now?
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Im so sorry to hear what's going on with your father. Have they ever gotten back to you with the genetic biomarker results? PD-L1? TMB? Did he have chemotherapy before the surgery? How many lymph nodes tested positive? Have they mentioned radiation therapy?
I'm a long term stage 4b survivor. It was everywhere. My avatar is me. If it glows it's cancer. From my liver to my head. So stage 4 is not a death sentence.
Radiation therapy is the standard of care for treating lung cancer that has spread to the Bones . From radiation alone to chemoradiation with immunotherapy added depending on the patient.
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His PD-L1 is only 5%. I read your story. You had PD-L1 over 99% which is really lucky. My father probably will not respond to immunotherapy that well, but we will try. He will see radiology oncologist next Monday. I know stage IV is not a death sentence, but based on his gene type KRAS g12V, his low PD-L1, his histology result is Poorly differentiated, I don’t have any confidence now. His tumor spread to lumbar which I think he may not be able to walk soon. I don’t want him to suffer pain, that’s my goal. However I don’t know who I should talk to. Doctor thinks it’s too early to think about that. I mentioned palliative care but doctor doesn’t really think that’s helpful. What else can I do? I don’t have siblings and all our relatives are overseas. I feel I am in the dark. Thank you! You are very kind that you always reply questions in this forum and very supportive!
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It's important to remember that up to 15% of people with no PD-L1 expression still respond to immunotherapy. While treatment options may be limited due to the KRAS 12V mutation, there are still viable approaches. Chemotherapy and immunotherapy have shown success for many patients. I don't know how well your father would tolerate carboplatin, but pemetrexed is generally well-tolerated, and many patients have been on it for years. Immunotherapy can also be tolerable, though responses vary. I've personally been on Keytruda for four and a half years.
Radiation is the standard treatment for bone metastasis and is highly effective. It can provide pain relief and tumor control, either as a standalone treatment in a palliative setting or in combination with systemic therapies for a more aggressive approach. Interestingly, the fact that the cancer is poorly differentiated could actually work in his favor, as poorly differentiated cancers often respond better to both radiation and systemic treatments that disrupt DNA, such as pemetrexed.
You might also explore clinical trials or off-label use of MEK inhibitors, which have shown promising results in some KRAS 12V-mutant cancers.
I'm concerned about your doctor's view on palliative care. Research and guidelines from leading organizations like the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) recommend integrating palliative care early in the treatment process for all cancer patients. This is not about giving up but rather ensuring symptom management and support from the start of treatment.
There may have been a misunderstanding, as hospice care at this point would indeed be premature. I suggest seeking clarification from your current care team or considering a second opinion to better understand your father's options.
ASCO Palliative Care Guidelines
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Thank you a lot! I will check with them on palliative care again. I hope he can tolerate the chemo. They start with low dose for him. If my father tolerated, I am going to ask for regular dose especially for pemetrexed. I may also ask for MEK inhibitors clinical trials. You are so knowledgeable! I feel bad that in the beginning of treatment, one doctor suggested chemo before surgery and another doctor suggested surgery first. I may chose the wrong doctor and plan for him.
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