Switching back to Pembro

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plastikos
Posts: 326
Joined: Wed Jan 14, 2015 6:09 am

Switching back to Pembro

Postby plastikos » Tue Mar 07, 2017 11:27 am

Hi all. Been gone for a while. Chemo took it's toll. As an update I have finished 4 rounds of chemo after a single dose of Keytruda in early December. Latest PET-CT showed almost all tumors (liver, nodes) have shrunk and are metabolically inactive save for one node (peripancreatic) which still has some activity, although weaker and smaller. I guess this is a good result so I will take it.

I am at the crossroads. My local onc who is my main doctor suggests to continue chemo. My onc in Singapore thinks the response is mainly due to the Pembro and suggests I switch back. I am MSI high. I trust them both and the fact that they have their own biases for the particular treatments they are suggesting is not lost on me. In the end I am choosing to take a risk at trying Pembro again for the better quality of life it offers. Hopefully it will work its magic. Still hoping against hope for a cure.
Last edited by plastikos on Tue Mar 07, 2017 7:09 pm, edited 2 times in total.
St. IV Colon CA @ 37, male, Kras wild, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab started 12/2016 -> pseudoprogression(?) -> biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab again
Sept 2017 - SIRT - > NED

User avatar
Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Switching back to Pembro

Postby Maia » Tue Mar 07, 2017 12:21 pm

I'm glad to hear you're doing well, and that you took such decition. Anti PD-1 will be probably approved this month, for MSI-high. Many responding to it just as monotherapy and, when doesn't work that way, it is clear that it packs a punch when combined with Avastin.

Atezolizumab/Bevacizumab Combo Attains 90% DCR in MSI-High mCRC
Published Online: Tuesday, Feb 07, 2017
- See more at: http://www.onclive.com/web-exclusives/a ... SQYED.dpuf

ADDING Avastin (bevacizumab) to Keytruda seems to pack an even greater punch for MSI-H / Lynch. Combo of anti PD-1/PD-L1 (Keytruda, Opdivo, atezo, durva, etc.) plus Avastin. See the trial Stephen is on viewtopic.php?f=1&t=51990

http://fightcolorectalcancer.org/blog/t ... ot-part-1/
http://fightcolorectalcancer.org/blog/t ... ot-part-2/

Just in case you still are looking for something else, I posted recently a couple of trials for a fellow in Singapore, here viewtopic.php?f=1&t=56745#p452895 He's MSS and those trials might be promising even for him (keep in mind that, in general, more anti-PD1 are equal, just other pharma)

A recent post that might be of your interest too (watch the video) viewtopic.php?f=1&t=57401

stu
Posts: 1028
Joined: Sat Aug 17, 2013 5:46 pm

Re: Switching back to Pembro

Postby stu » Tue Mar 07, 2017 4:16 pm

Hi ,
Delighted to hear how well chemo works for you. You have this well thought out. Maia is a star!!
Take care,
Stu
supporter to my mum who lives a great life despite a difficult diagnosis
stage4 2009 significant spread to liver
2010 colon /liver resection
chemo following recurrence
73% of liver removed
enjoying life treatment free
2016 lung resection
Oct 2017 nice clear scan . Two lung nodules disappeared
Oct 2018. Another clear scan .

plastikos
Posts: 326
Joined: Wed Jan 14, 2015 6:09 am

Re: Switching back to Pembro

Postby plastikos » Tue Mar 07, 2017 7:08 pm

Maia wrote:I'm glad to hear you're doing well, and that you took such decition. Anti PD-1 will be probably approved this month, for MSI-high. Many responding to it just as monotherapy and, when doesn't work that way, it is clear that it packs a punch when combined with Avastin.

Atezolizumab/Bevacizumab Combo Attains 90% DCR in MSI-High mCRC
Published Online: Tuesday, Feb 07, 2017
- See more at: http://www.onclive.com/web-exclusives/a ... SQYED.dpuf

ADDING Avastin (bevacizumab) to Keytruda seems to pack an even greater punch for MSI-H / Lynch. Combo of anti PD-1/PD-L1 (Keytruda, Opdivo, atezo, durva, etc.) plus Avastin. See the trial Stephen is on viewtopic.php?f=1&t=51990

http://fightcolorectalcancer.org/blog/t ... ot-part-1/
http://fightcolorectalcancer.org/blog/t ... ot-part-2/

Just in case you still are looking for something else, I posted recently a couple of trials for a fellow in Singapore, here viewtopic.php?f=1&t=56745#p452895 He's MSS and those trials might be promising even for him (keep in mind that, in general, more anti-PD1 are equal, just other pharma)

A recent post that might be of your interest too (watch the video) viewtopic.php?f=1&t=57401

Hi Maia. As always thanks for the information. Yup I have actually never been on Avastin (I have never progressed on any of my pasts regimens) so it's always an option if the need arises.
St. IV Colon CA @ 37, male, Kras wild, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab started 12/2016 -> pseudoprogression(?) -> biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab again
Sept 2017 - SIRT - > NED

plastikos
Posts: 326
Joined: Wed Jan 14, 2015 6:09 am

Re: Switching back to Pembro

Postby plastikos » Mon May 08, 2017 11:57 am

Update:

Had 3 infusions of Pembrolizumab (every 3 weeks). PET-CT still shows basically the same lesions with a very minimal decreases in their respective sizes. But all of them are now non-hypermetabolic on PET. I was hoping, maybe even expecting, a more dramatic change but all in all it is still good I think. Not sure how long PD-1 inhibitors take to take effect.
St. IV Colon CA @ 37, male, Kras wild, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab started 12/2016 -> pseudoprogression(?) -> biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab again
Sept 2017 - SIRT - > NED

Lee
Posts: 5848
Joined: Sun Apr 16, 2006 4:09 pm

Re: Switching back to Pembro

Postby Lee » Mon May 08, 2017 5:00 pm

plastikos wrote:Update:

Had 3 infusions of Pembrolizumab (every 3 weeks). PET-CT still shows basically the same lesions with a very minimal decreases in their respective sizes. But all of them are now non-hypermetabolic on PET. I was hoping, maybe even expecting, a more dramatic change but all in all it is still good I think. Not sure how long PD-1 inhibitors take to take effect.


Decrease in size even minimal is a good think. I understand your frustration in wanting a more dramatic change.

Are you considering Avastin?

All the best,

Lee
rectal cancer - April 2004
46 yrs old at diagnoses
stage III C - 6/13 lymph positive
radiation - 6 weeks
surgery - August 2004/hernia repair 2014
permanent colostomy
chemo - FOLFOX
NED - 10 years and counting!

plastikos
Posts: 326
Joined: Wed Jan 14, 2015 6:09 am

Re: Switching back to Pembro

Postby plastikos » Mon May 08, 2017 8:23 pm

Lee wrote:
plastikos wrote:Update:

Had 3 infusions of Pembrolizumab (every 3 weeks). PET-CT still shows basically the same lesions with a very minimal decreases in their respective sizes. But all of them are now non-hypermetabolic on PET. I was hoping, maybe even expecting, a more dramatic change but all in all it is still good I think. Not sure how long PD-1 inhibitors take to take effect.


Decrease in size even minimal is a good think. I understand your frustration in wanting a more dramatic change.

Are you considering Avastin?

All the best,

Lee

Thanks. Onc hasn't mentioned Avastin yet. Did you mean combination with the Pembro? Is the data on it out?
St. IV Colon CA @ 37, male, Kras wild, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab started 12/2016 -> pseudoprogression(?) -> biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab again
Sept 2017 - SIRT - > NED

Lee
Posts: 5848
Joined: Sun Apr 16, 2006 4:09 pm

Re: Switching back to Pembro

Postby Lee » Tue May 09, 2017 11:20 am

plastikos wrote:Thanks. Onc hasn't mentioned Avastin yet. Did you mean combination with the Pembro? Is the data on it out?


I'm not aware of any data on this at this time. Was just wondering if you were thinking of it as you were "hoping for a more dramatic change" under current treatment plan.

Keytruda has been successful for BeansMama, I'm assuming you are getting the same thing. Maybe give it a bit more time.

Any comments from your Onc on your most recent PET CT?

Lee
rectal cancer - April 2004
46 yrs old at diagnoses
stage III C - 6/13 lymph positive
radiation - 6 weeks
surgery - August 2004/hernia repair 2014
permanent colostomy
chemo - FOLFOX
NED - 10 years and counting!

User avatar
Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Switching back to Pembro

Postby Maia » Tue May 09, 2017 8:23 pm

plastikos wrote:Onc hasn't mentioned Avastin yet. Did you mean combination with the Pembro? Is the data on it out?


The data is out for atezolizumab + bevacizumab --the one quoted above in this post. Atezo is an anti PD-L1, pembrolizumab is an anti PD-1, but so far, in general, they are showing practically similar results.
You always can go for almost *any* trial for MSS CRC or solid tumours that combines one anti PD-1/PD-L1 plus something else: IDO1 inhibitor, GITR inhibitor, TIG --all immuno--, even chemo or targeted agent. That X, in addition to the PD-1/L-1 checkpoint inhibitor, might be enough to make a MSI-high tumour more responsive to treatment.

User avatar
Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Switching back to Pembro

Postby Maia » Tue May 09, 2017 8:32 pm

plastikos wrote:Update:

Had 3 infusions of Pembrolizumab (every 3 weeks). PET-CT still shows basically the same lesions with a very minimal decreases in their respective sizes. But all of them are now non-hypermetabolic on PET. I was hoping, maybe even expecting, a more dramatic change but all in all it is still good I think. Not sure how long PD-1 inhibitors take to take effect.


Minimal decreases, non-hypermetabolic on PET, not experience adverse effects is wonderful. You just keep going, and living. Sometimes immunotherapy takes many time to work --there are reports of people who left trials, because side effects or apparent progression, and have results from the immunotherapy months after discontinuation.
If you search for Stephen's case --trial with atezolizumb + avastin, he's MSI-high; I provided you the link in a previous post-- you will see that he's only recently NED, after more than one year on the trial --maybe two, I don't remember now.
The key is how you're feeling.

plastikos
Posts: 326
Joined: Wed Jan 14, 2015 6:09 am

Re: Switching back to Pembro

Postby plastikos » Wed May 10, 2017 10:12 am

Lee wrote:
plastikos wrote:Thanks. Onc hasn't mentioned Avastin yet. Did you mean combination with the Pembro? Is the data on it out?


I'm not aware of any data on this at this time. Was just wondering if you were thinking of it as you were "hoping for a more dramatic change" under current treatment plan.

Keytruda has been successful for BeansMama, I'm assuming you are getting the same thing. Maybe give it a bit more time.

Any comments from your Onc on your most recent PET CT?

Lee

The plan is to continue Pembro for now since it is an improvement in terms of the FDG uptake (or lack thereof) on PET.
St. IV Colon CA @ 37, male, Kras wild, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab started 12/2016 -> pseudoprogression(?) -> biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab again
Sept 2017 - SIRT - > NED

plastikos
Posts: 326
Joined: Wed Jan 14, 2015 6:09 am

Re: Switching back to Pembro

Postby plastikos » Wed May 10, 2017 10:14 am

Maia wrote:
plastikos wrote:Update:

Had 3 infusions of Pembrolizumab (every 3 weeks). PET-CT still shows basically the same lesions with a very minimal decreases in their respective sizes. But all of them are now non-hypermetabolic on PET. I was hoping, maybe even expecting, a more dramatic change but all in all it is still good I think. Not sure how long PD-1 inhibitors take to take effect.


Minimal decreases, non-hypermetabolic on PET, not experience adverse effects is wonderful. You just keep going, and living. Sometimes immunotherapy takes many time to work --there are reports of people who left trials, because side effects or apparent progression, and have results from the immunotherapy months after discontinuation.
If you search for Stephen's case --trial with atezolizumb + avastin, he's MSI-high; I provided you the link in a previous post-- you will see that he's only recently NED, after more than one year on the trial --maybe two, I don't remember now.
The key is how you're feeling.

Thank you Maia. That is so reassuring. Yes quality of life is definitely much much better now compared to before.
St. IV Colon CA @ 37, male, Kras wild, MSI-high (2014)
11/2014 Right Hemicolectomy + Liver Resection
12/2014 - 6/2015 FOLFOX + Cetuximab
10/2015 - Recurrence liver
Liver resection 10/2015
FOLFIRI 11/2015 - 5/2016
Recurrence liver, nodes 11/2016
Pembrolizumab started 12/2016 -> pseudoprogression(?) -> biliary obstruction -> biliary stenting
Chemo 4x: most mets inactive and smaller on PET-CT
March 2017 - Back on Pembrolizumab again
Sept 2017 - SIRT - > NED

Lee
Posts: 5848
Joined: Sun Apr 16, 2006 4:09 pm

Re: Switching back to Pembro

Postby Lee » Wed May 10, 2017 5:27 pm

Maia wrote:
The data is out for atezolizumab + bevacizumab --the one quoted above in this post. Atezo is an anti PD-L1, pembrolizumab is an anti PD-1, but so far, in general, they are showing practically similar results.
You always can go for almost *any* trial for MSS CRC or solid tumours that combines one anti PD-1/PD-L1 plus something else: IDO1 inhibitor, GITR inhibitor, TIG --all immuno--, even chemo or targeted agent. That X, in addition to the PD-1/L-1 checkpoint inhibitor, might be enough to make a MSI-high tumour more responsive to treatment.


We are fortunate to have you, thank you for all that you do.

Plastikos, I wish much success with the Pembro, that it does kick those nasty cell into the next universe.

Lee
rectal cancer - April 2004
46 yrs old at diagnoses
stage III C - 6/13 lymph positive
radiation - 6 weeks
surgery - August 2004/hernia repair 2014
permanent colostomy
chemo - FOLFOX
NED - 10 years and counting!

Wonderfullymade
Posts: 140
Joined: Tue Jan 12, 2016 4:33 pm

Re: Switching back to Pembro

Postby Wonderfullymade » Fri May 12, 2017 8:13 am

Another post I absolutely needed to read today! I have been feeling the sameway Plastikos! And guilty about it! Stable is good,but...have seen some fantastic results in some people and have been wondering how long does it take myself! And thank you again Maia! You are truly a ray of light/hope for me also!
I am so grateful that if I have to be on this journey I dont have to go it alone! I've been face down in the mud lately...thanks for rolling me over and lifting me out!
Wonderfullymade
DX 3/2015 53
Stage IVa CC w/liver met
BRAF/KRAS wild type MSI-High (MLH1, PMS2) not Lynch
Folfox 3 cycles
5/2015 ER for subtotal colectomomy due to perforated colon, ovary removed
Folfuri/Pantiumumab 5 cycles
8/2015 liver resection, gallbladder removed and new LN
10/2015 CT scan new nodes
10/2015 Pembro started CEA 2.2
5/2017 stable lung things, coltis, lymph nodes stable cea 1/2017 1.1
9/2017 NED CEA 1.1 ( stopped Pembro)
2/2019 ER for DVT/ PE
2/2019 clean CT (NED) CEA 1.1

User avatar
Maia
Posts: 2443
Joined: Fri Aug 24, 2012 8:00 am

Re: Switching back to Pembro

Postby Maia » Fri May 12, 2017 2:16 pm

You have every reason to be hopeful right away, 'MSI-high guys and girls'. As someone said, you are the lucky amongst the unlucky. Maybe we who are searching for clinical trials are neglecting you a bit, and focussing more on MSS, that is a more difficult target : )
As I've said, almost every combination immuno trial for MSS CRC will take MSI-H CRC, but you even have some well designed trials addressed to MSI-High, and some of them might be reproducible outside the trial, with the help of the oncologist and applying to the access program from the companies producing the drugs.


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