Dr. Nagourney Answers Qs on Cancer, Insurance

Dr. Robert Nagourney, cancer expert

Lifechanger Dr. Robert Nagourney, a renegade oncologist treating cancer with unique remedies, is answering your questions.

Q: I'm trying to help my nephew. He was diagnosed with testicular cancer 2 1/2 yrs ago and now his cancer is in his liver. His oncologist has pretty much said there is nothing else we can do? Well my nephew has a lot of life left in him to give to his 7 yr old daughter and wife, that we don't know where else to turn. He has had surgeries, stem cell and chemo. Please help I have lots of questions, what type of insurance is accepted, cost, additional locations. I hope to hear real soon as time is critical. God Bless. -E.Hidalgo

A: Mr. Hidalgo,

Testicular cancers are sub typed by their microscopic features and circulating tumor markers like HCG and AFP. The most treatable form is seminoma. The Non-seminoma tumors are then divided into Embryonal, Choriocarcinoma, Yolk-sac, Malignant teratomas and other rarer forms. The principal therapies all include Cisplatin. A recent review from France (Proceedings Amer Society of Clin Oncology abs 5030, 2009) identified location of tumor, and height of the tumor markers as prognostic factors. In the relapsed state, there are "salvage" regimens that can be considered including the use of Taxanes, Gemcitabine, Ifosfamide, Oxaliplatin and Topoisomerase I inhibitors like Topotecan and Irinotecan. The response rates are variable. We have studied a moderate number of tumors of this type. Our interest in the drug Gemcitabine combined with a platinum derivatives like Cisplatin or Oxaliplatin or possibly combined with Ifosfamide would be possibilities as would the other classes of drugs. If there is readily accessible tumor for surgical biopsy, these types of cancers can be tested for their drug response profiles. Specimens need to be processed and received sterile within 24 hours of biopsy. The full analysis cost is $3,500 US and insurance coverage is variable. To be a candidate, a patient would need to be off active chemotherapy for 4 weeks and well enough to consider further chemotherapy.

For your information, a review of the pharmacotherapy (drug therapy) of these tumors in the relapsed state was published by Kollmannsberger, C et al in Exp. Op. Pharmacotherapy in Sept 2008.

Q: I have stage 3b Lung Cancer. At first it was only in the top right lung. That part was removed 2-13-07. In 2008 the cancer went into my left lung. And now in 2009 it has gone to my tailbone. I will have just finish 3 weeks of radiation this Monday. Tuesday I will start chemo for the 3rd time. I am sure everyone would like to know what kind of insurance you will accept. I am in Calif. I receive medicade and medi-cal. Or is it on a case by case? - Rhonda

A: Dear Rhonda:

Stage IIIB Lung cancer unfortunately often recurs despite the best therapies. Thus, we see a large number of patients with this problem. With the development of newer classes of drugs including the Taxanes, Pemetrexed, Gemcitabine, Vinorelbine, Irinotecan, Avastin, Tarceva and Erbitux, oncologists can often provide responses even in the relapsed setting. Non Small Cell Lung Cancers are among the most common tumors that we process in our laboratory. Depending upon which drugs you have received, there may be active drugs and combinations worth considering. Oncologists are increasingly using patient's own features to help guide drug selection including histology (squamous cell or non-squamous cell), patient's gender and racial origin, and genetic features to point (in a general sense) toward classes of drugs.

In our laboratory we then take that process one step further by using the patient's own cells to actually match their tumor the most effective drugs. As with other patients, we need fresh tissue and it must be processed sterile and promptly. Patients must be well enough to consider therapy and must be off active treatment for 4 weeks. If our analysis then identifies a good drug or combination, patients can usually receive therapy under the care of their own doctor. Our initial focus is always to identify activity for the FDA approved and recognized drugs for your disease. In essence, we start with the same deck of cards (treatment options) but we shuffle them so as to come up with the best possible hand for each individual.

Q: My husband had sinus nasal undifferentiated carcinoma 6+ years ago. He underwent intense chemo and radiation. All was fine until this past year. This same cancer (which was in the sphenoid cavity) has now metastasized to the liver. He has had infusion of cisplatin, urbatux, and leaves wearing a fanny pack 24/5 of 5fu. Then, they attempted to remove 3/4 of liverous tumor and found the 'healthy' part had 4 small tumors. So did not section and instead installed a pump to direct chemo at liver. Found out in January that it did not work. Began infusion the next day and removed the internal pump a week later by surgery. 2+ weeks later he had intense chemo again. Very debilitated, yet still battling. postponed the next chemo to an extra week later. Do you have any suggestions, help for us? He is 53 years.
- Nanci Paskell

A: Nasopharyngeal tumors are initially treated with combined modality radiation and chemotherapy. It sounds like your husband received the right approach. Recurrences are not uncommon, however. These tumors can vary from squamous cell to Neuroendocrine to spindle cell in their microscopic appearance. The treatments to date sound quite reasonable, but as you can appreciate, may not work for every patient. Depending upon the drugs received to date, there may be options like Irinotecan based combinations or possibly Gemcitabine based therapies. Ease of access to the areas in the liver would determine if the laboratory based approach would be appropriate. These cancers can be aggressive and relatively drug resistant so the likelihood of finding active therapies is uncertain. If he is strong enough to consider additional therapy, there may yet be options for him.

Q: My mom was diagnosed with stage 3b lung cancer. They told her that she could not have surgery nor radiation. She has had 4 chemo treatments but there has been no change. She is now starting a chemo pill called tarceva which she needs to take every day. I would love for her to see you. I will go to the website but in the meantime any info will help. Does Insurance cover the cost of seeing the Dr. I am sure that airfare and stay would have to be paid by us but if insurance can help out with the medical part of it?- Jennifer

A: Unfortunately, only 30% of patients with Non Small Cell Lung cancer respond to first line therapy today. Tarceva, a new member of the "targeted" therapy drugs is a reasonable and recognized 2nd line therapy in this setting. If your mother is Asian and a non-smoker, her odds are better. The available test for this drug are the EGFr mutation analyses conducted upon the biopsy material removed at the time of diagnosis.

We have recently reported our results with 1st line, untreated, metastatic lung cancer patients who received therapy based upon their (EVA/PCD) individual drug response profiles. In this Phase II trial of 25 patients we had a response rate of 54% with many very durable remissions (several years and counting) (Nagourney R et al Proc Amer Soc of Clin Oncol, 2009). In the recurrent setting we cannot expect quite such good results, however...

As with all our patients, the use of our tests makes the most sense in people who are well enough to undergo further therapy, for whom a biopsy can be obtained without undue difficulty (preferably lymph node biopsy or fluid removal) and who are off active therapy for 4 weeks prior to biopsy. The costs are $3,500 with some insurers paying in full and others not. It might be worth inquiring with your carrier.

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