Nicholas Johnson8 said:Hey everyone.
My dad was recently diagnosed with lung cancer, and there’s a suspicion of liver metastasis.
The diagnosis was confirmed via bronchoscopy, where they "found some malignant cells," along with a PD-L1 mutation (90% expression). We also had a CT scan showing a suspicious lung lesion about 4 x 4 cm, alongside a suspicious lesion in the liver.
The exact type of carcinoma hasn't been confirmed yet because there weren't enough malignant cells in the sample.
My dad is 79. He had a heart attack back in 2010. We've actually been monitoring this lung lesion since 2010 (it was 1x1 cm) with a thoracic surgeon who kept insisting it was a benign process because it was growing so slowly. And now, here we are...
Dad is in good general health—he isn't showing any symptoms (considering the suspected stage), he hasn't lost weight, no coughing, no pain.
So, here's the thing... Today we saw an oncologist, who first sent us for an MRI of the liver to rule out whether that metastasis is actually there.
He told us that if there’s no metastasis in the liver, we should go with radiation, plus potentially chemotherapy if his age allows him to handle it.
If the metastasis is confirmed, then he goes on immunotherapy because of that 90% PD-L1 expression.
I’m wondering why we can't just start immunotherapy immediately, regardless of what that liver lesion shows? I asked the oncologist, and he said immunotherapy is only administered for metastatic carcinoma.
From what I've read, immunotherapy (specifically Keytruda/pembrolizumab) shows pretty good outcomes and life extension for carcinomas with PD-L1 expression.
Is this just the oncologist's personal preference, should we seek a second opinion, or is it simply how things work?
I feel like we're missing a window for immunotherapy given that PD-L1 expression.
This comes down to a registered indication covered by Medicare. Regardless of what the clinical studies say, Medicare and Big Pharma have agreements in place where therapy is only approved at their expense for metastatic diseases. It’s the same deal you see with biologics for arthritis—they’d rather wait until a person is completely deformed and becomes an even bigger burden on Medicare than they would expand the indications so the patient could actually live a productive life.
It raises a logical question: why not, and can the patient just pay for the therapy themselves? The answer is that someone clearly has an incentive for the first part, and for the second, you can't exactly go to a public hospital and receive treatment with a drug paid for out of your own pocket. Because of laws dating back to the era of political corruption, anything a hospital doctor prescribes on a standard prescription that isn't on the approved list of drugs for a specific indication is funded by the hospital's budget. Naturally, oncologists, fearing repercussions (since the drug is expensive and strains already thin hospital budgets), won't do it—they just wash their hands of it and follow the "rules."
Of course, some doctors operate on a basis of trust with the patient, believing the patient won't sue the hospital if the doctor provides treatment in that "gray area" using a drug the patient bought privately. The other option is private healthcare, which is much more expensive.
In short, it's one of those beauties of the American healthcare system that comes bundled with a diagnosis—and sometimes, the system is harder to handle than the illness itself.
Sent from my Samsung using Reddit
