When it Works, it Works

Despite the toxicities and haphazard administration schedules associated with many chemotherapy combinations, some patients have dramatic responses to therapy. One such patient was seen in consultation today. In September 2009, this 46-year-old gentleman presented with bilateral plural effusions associated with bilateral pulmonary infiltrates, mediastinal adenopathy, ascite, and respiratory failure. He was immediately intubated and stabilized.

His condition was so grave that no one wished to give him any therapy. A medical oncologist consulted and examined the patient’s extremely poor performance status. I was then asked to provide a second opinion. After discussing the findings with the primary oncologist, we agreed to try empiric chemotherapy with a combo known as folfox. Our reasoning was that this young man with adenocarcinoma would stand the greatest chance of benefit from platinum based therapy and that 5FU — though not often used in lung — would have activity both in thoracic and gastrointestinal primaries. This highly undifferentiated neoplasm could not be better characterized to identify a likely site of origin.

Contrary to everyone’s expectations, the patient had a dramatic recovery. He was first weaned off the respirator, then transferred to physical therapy and, finally, discharged for follow up and out patient chemotherapy. Now, seven months later, the patient is back to normal activities. In my discussions with this patient, I suggested he remain on therapy and I made no recommendation that changes or biopsies be considered. It is my belief that this patient is a biological responder. His underlying disease retains the capacity to respond to therapy. For this reason, I encourage the patient to follow up if he shows signs of progression. It is very possible that other classes of drugs can yet provide benefit when necessary. My reasoning is that the patient has a tumor that retains programmed cell death capacity. The selection of therapies in the future may well continue his excellent response. Nonetheless, I would not intervene at this time based on the old saying that “if it isn’t broken, don’t fix it.” My final point in this patient, despite my misgivings about randomly administering therapies, is that cancer therapies can be extremely effective and well tolerated. Our job is to match the most active, least toxic drugs for each patient.