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Comment by nyx | Hacker News Reader

Stage IIIC NSCLC, specifically a superior sulcus tumor, advanced enough to be considered inoperable. Standard of care in this case was induction radiotherapy, followed by a single course of combination chemotherapy consisting of carboplatin, pemetrexed, and pembrolizumab (the last of which is the cutting-edge immunotherapy I'm talking about; brand name Keytruda.) After that, patients are prescribed the pemetrexed and immunotherapy alone for a long 2-year "maintenance" course, at which point treatment options will be reassessed.

Surgery was not an option here because of the size and location of the mass, but after the initial course of chemo a PET-CT showed an 80% reduction in size. After some time on pembrolizumab, symptoms continue to improve and surgery may be back on the table soon.

(edited for a more accurate picture of maintenance treatment; thanks to borbulon for refreshing my memory)

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Thank you for pointing out the standard of care in this case, given inability to resect, was the immunotherapy from the start. Obviously very specific for that type of lung cancer and the state of your contact's tumor, but I've been learning more and more about this and have been told by multiple oncologists that immunotherapy is typically only given after more conventional treatments are first attempted and fail to stop progression or shrink the mass(es). Needless to say that's far from categorical so in my next conversations I can be a bit more educated in my questioning.

And 80% reduction after that first course... Amazing. How long after the first course did they do the scan that showed that reduction?

Btw, very happy for you (and even moreso for your contact). Great news.

The scan that indicated the 80% reduction was after just a couple of weeks, if I recall correctly.

Since you're talking about immunotherapy not typically being a first-line treatment, I'll share a morbidly interesting fact that underscores some of the, er... quirks of the US medical system. The oncologist treating my relative initially staged my relative's cancer in the electronic health records as stage IV, despite no evidence of metastasis (the usual criterion)--he explained that he did this specifically in order to pursue first-line Keytruda (which is indicated for stage IV but not stage IIIC) and have it be covered by insurance.

I don't understand how medical insurance companies can choose what treatments can be applicable to what patients and yet not be as liable as a doctor for medical malpractice.

It’s not that they choose the treatment, you can get whatever treatment you want. They just say that they won’t pay for treatment other than X. This is unavoidable, really: if you look at countries with public healthcare system, like eg. UK, the (state) insurer there also makes decisions as to which treatments are covered, and which patients are eligible to get them. If anything, they are more conservative than private insurers in US: due to public nature, typically they do not offer higher range of treatments to customers who pay higher premiums. Instead, the coverage is “one size fits all”, and to limit costs, covered treatments options are seriously limited compared to what private insurers offer in US, especially in countries other than the wealthiest ones: in Poland, for example, cancer treatments available to patients on government healthcare are at least a decade or two behind the state of the art. Of course, the flip side is that you then get to see how cheap health care per capita is in Poland, and gripe about outrageous costs in US.

Thanks for the info on the timing. And that's my kind of oncologist. Risk in doing that on multiple levels, of course, but reassuring that some physicians are willing to do what's right vs what fits into into an insurance company's flow chart.

Not sure about lung cancer, but there's positive results in other cancers for earlier immunotherapy !

https://oncologypro.esmo.org/meeting-resources/esmo-congress...

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