Rob: This is a tough question. It’s a little beyond my comfort zone, so I’ll just offer some ideas as to how I think I’d approach it.
First, you may have this, but I’d like more information on the pulmonary nodules before making this decision. How many are there, precisely, and what is their history on scans? To my knowledge, while nodules in non-smokers are common (smoking makes this far tougher to evaluate because nodules are ubiquitous and variable), nodules that demonstrate sustained growth over time are usually seen as likely mets in a rectal cancer patient. Of course, you and your team know that. But when they’re small, not much can be done other than systemic treatment, which is usually capable of extending PFS but, as you note, not OS. There are, of course, cases of complete remission (including, I think, Claudine’s husband) on standard chemo, but these are at best uncommon (to rare). Improved PFS on chemo is often of value, but so is a few months of good health unimpeded by chemo while monitoring, which leaves the tough decision.
I think I’d want that decision—whatever it is—to be part of a strategic plan. After the above questions are answered, I’d want to know if it’s reasonably likely that with/without chemo there would be a promising surgical or ablation path. If that’s in the cards, how better to get there? If not, which course is likely to give you more/better time (and keep in mind that promising treatments/trials may appear in the near future—pulmonary disease w/o more usually has a fairly long survival)? Finally, if your team just can’t say now, what is the specific rationale for their respective recommendations? It sounds like you may have gotten that from your long-standing oncologist but perhaps not the others? I tend to ask very specific questions, including odds of outcomes (I always bend over backwards to say “I understand it’s a guess, won’t hold you to it, etc.”). Answers sometimes appear after chipping away for a while.
Sorry, that was a bit all over the place. At the risk of repetition, I’ll try to list specific potential questions:
1. How many suspect nodules are there? What is the scan history/growth of each? I know you said there are “a handful” of micro nodules under 1mm, but did they recently appear? Have the larger nodules grown? (I know it’s within radiological error margins at this stage, but trends may be there across the group of nodules.)
2. With or w/o chemo, what is the likelihood of getting to the point where surgery or ablation can be productively employed? Is one course or another more likely to get there?
3. What is the specific rationale for the respective recommendations (chemo or no?)? [This is probably the short cut: I would have each “make their case.” Sounds like your original oncologist has, but how about the others?]
4. If you wait and these progress, does that make surgery or ablation tougher? Would it make remission on chemo even less likely, or increase the likelihood of further metastasis? If so, how much? (One unpleasant question that must be asked here, I think: If these progress, will the doctors or the healthcare plan just “throw up their hands” at some point as to ablation/surgery? In other words, is there a chance you’ll lose control of options?)
5. Is there a PFS benefit to starting chemo now to try to find an ideal regimen? Is there a PFS benefit to starting chemo earlier, or can you simply “catch up”?
6. Finally, I have dealt with this solely as a question of pulmonary nodules, but would there potentially be a chemo benefit in the other areas where you had mets? PFS or OS?
That’s what I thought of. Sorry if it’s unclear or confusing. I know I blathered on a bit here, which I try to avoid. (Sorry.) It’s definitely a hard call because there are so many variables. It also depends on your own personal goals and valuations of outcomes. You are very well-informed, strong, and positive, so I’m confident you’ll make a good choice. As always, may the road rise with you!
7/19: Rectal cancer: Staged IIIA, T2N1M0
approx 4.25 cm, low/mid rectum, mod. well diff.; lung micronodule
8/22 -10/14 4 rounds FOLFOX neoadjuvant, 3 w/Oxiplatin (side effects/reduced 70-75%)
neoadjuvant chemorad 11/19
4 rounds FOLFOX July-August 2020
ncCR 10/20; biopsies neg
TAE 11/20, tumor cells removed
Chest CT 3/30/21 small growth in 2 nodules (3 and 5mm)
VATS 12/8/21 sub-pleural met 7mm.
SBRT nodule 1/22
CT 3/22: Clear
Thoracic CT 5/19/22 Clear
6/20/22 TAE rectal polyp benign