Platinum resistant, anyone?

I have just been told I'm recurring after 5-1/2 months, which means I'm platinum resistant. I'm told my chemo options are limited, as well as the chances for another remission are diminished.

Is anyone here on the board that can give me some kind of hope? Anyone platinum resistant and hopefully gone back into remission with something else? If not, what is your life like now, really? (as far as how constant are your treatments, how controlled is your cancer). I am literally shaking in my shoes with this news. I don't even have to tell you what a nightmare this is because you all were here before me and have been through just as much and more -- and I'm sure you all fully know well just how absolutely, unbelievably, much, this sucks.

The docs are discussing (amongst themselves) a regimen for me which I believe will be weekly chemo (Taxol) combined with something else. They are also looking at Avastin if insurance covers it, other options - Gemzar, topetecan (sp), doxirubicin (sp), etc.

My doc asked me to read through them all and become familiar with them because he wants me to be involved with the decision making as well (instead of him just telling me what to do). He will lay out the pros and cons of all. From my understanding, there apparently is no "standard of care" for platinum resistance, it's basically try this one to see if it works and if not, move on.

I'd like to hear real life situations. I'm bracing myself, lay it on me straight out, please.... I wanna know everything... thanks...

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Hi ReneeK1

I read your posting and my heart goes out to you. One thing I will tell you is never never let any doctor make you feel defeated. There are standards that the medical profession places on its patients. There are so many woman who have been in your shoes and are still here 5 10 and 20 years later. Never give up hope and stay strong. Research all the drugs you listed so that you can make informed decisions on treatment. There are so many drugs available and never forget about clinical trials. Go to the OVCA site. Alot of woman that have had each of these drugs are on this site and explain the side effects and also many have gone into remission.

STAY STRONG AND Keep the HOPE. My prayers and best wishes are with you.

Elaine

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Yes, for sure stay strong. I was in your shoes and am going into my fifth year. I also was on the standard Taxol and Carboplatin for 6 rounds. When I completed that regiment my CA125 was 100. I asked my doctor how come I was still so high. He told me that I would continue to see it go down.....but it didn't. When I went back a month later for another blood test, my tumor marker had gone up to 212... I, too, was shaking in my shoes and thought that was it for me, but it wasn't. Like Elaine said, there are many, many, different kinds of chemo that work well. After deciding that my relationship with my doctor was over because I had no faith in him or his next plan of treatment, I changed to a research hospital. They were the people who really made me feel different about this disease and the life I can still have. A good quality life. In many cases the disease will be chronic where you will need to continue chemo for the rest of your life which could be 20 - 30 years....... so, don't stop believing. Honestly, Gemzar worked very well for me...never went into any remission, but never felt sick and continued with my daily routine. Anyway so many different choices can be made, consult with others. They may take you off Taxol and have you go back to it in a couple of years again with the Carbo. Your cancer is resistant for now for this type of chemo, but others will definitely work for you. It did for me. Don't be discouraged! Please keep me in your list if you wish. I'd like to help if I can. Thanks, Carol

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OMGosh I think this is the first time I've breathed out since I found out. Thank you.
Please tell me, Elaine, where is the ovca site, and Carol, have you gone into complete remission at all during the 5 years? Do they give you as strong doses of chemo as when you were going through your first regimens? And can you continue with a good quality of life even on chemo all the time, like aren't you sick, do you have bone aches or that exhaustion you get, or other chemo side effects like neuropathy, etc.? IP Cisplatin knocked me on my butt...carboplatin wasn't too bad, nor paclitaxel but that messed my bones up.

I go to Sloan Kettering, but this doctor gave me the stats after questioning from me on them, he hasn't so much made me feel defeated as my imagination has and the words "the cancer has returned", "chronic cancer" and "chemo-resistant" have. My mind went into a blur after that and everything was like a bad movie. I'm still digesting all the info and we haven't even really discussed the planned treatments yet.

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When my gyn/onc and I were discussing the probability of a recurrence (before we knew for sure, but suspected), his original plan for me was Gemzar/Carbo. I did the 6 rounds of Taxol/Cisplatin, finishing in April of '08. I specifically asked if I were then platinum resistant, and he indicated that I was not. I'm not sure exactly how they decide. My CA 125 was normal in July, but 154 in October. It didn't jump that high overnight, so to me, it seems it probably started climbing within that 6 month window. I think the original regimen worked. My CT scan was good, my CA125 was low. It just didn't "stick." If that is the criteria , then maybe I am platinum resistant. I'll ask again when I see him next.

As I mentioned in another thread, I am now on Doxil alone. It sounds like a very manageable drug, all things considered. It is hard to know in advance, because we never know how we will react. I had so few problems with the Taxol/cisplatin and the IP administration that I am not a good gauge. Doc said I did "spectacularly well." I think he is a little surprised that I recurred so fast, especially after doing so well with the IP Cisplatin.

I will tell you what my gyn/onc said, FWIW. After he decided against the Gemzar/carbo, his choice was between Doxil and Topo. He said the Topo would be more frequent and cause more side effects. I asked why would anyone choose Topo over Doxil in that case. He said sometimes if he uses Doxil first, it is harder for the body to withstand the Topo later. I should have asked more questions, but I was still kinda shell shocked that day, facing the reality of cancer again. I am not sure, but I think he based his choice partly on how I handled the first round. But I think I would make a note to ask your doc about that. My doc seems to feel he can use certain drugs in a certain sequence with better results.

He has indicated that gyn/oncs vary a good bit in their approaches. That seems to be the case on this Board. I have done a lot of my own research, but ultimately, I rely on his recommendation about chemo. OTOH, he is not a big fan of supplements, so I will rely on my own research and others' advice in that area.

I will say this. He is a very optimistic doc, yet realistic. A woman I know just died of stage 4 ovca. He had told her it was time for hospice about 2 months before her death. He has told me consistently that he will tell me when it is time to worry. He said he understands that I am scared and why, that he would wonder if I weren't concerned, but it is not time to worry. I am trying to trust him on that one.

I have an aunt in her seventies who had ovca and a recurrence...25 years or so ago. I hang onto that.

I also have to remind myself from time to time, that for the most part, women who are long term survivors are so busy living their lives that they don't come to boards like this much. Sometimes I have to take a break, I get overwhelmed thinking about all of us who are frightened, having to deal every day with a life threatening illness. And then it makes me mad. And I think that is better. If I feel mad, then by god, I'm gonna fight.

You are in my thoughts, Renee. Take a deep breath, hon. (Cancer cells hate oxygen, you know.) Arm yourself with information. Then fight like hell.

Holding your hand through cyber space.

With love,
Jenn

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Hi Jenn, I recognize you from another post. We have very close timelines and VERY similar feelings. I also had great numbers, my CA-125 sunk to 8 -- so 3 months ago I was really optimistic!

Carol, I want to let you know I went to your profile and read your journal so you do not need to rehash your story again... I see lots of women on there in our boat.

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Do you know if there is a difference between serous papillary ovarian cancer and serous papillary adenocarcinoma? I was diagnosed with the former and the pathologist did not grade my cancer. It is almost a year later and I have had my oncologist fax a request to the pathologist 3 times now and still no response. I even called the department myself twice. I had the surgery and then 6 IV treatments of the taxol/carbo. My CA125 went from almost 900 to 8, but at my last checkup was 14. That was about a month ago but I have been having odd symptoms. My gastric reflux is breaking through my proton inhibitor medication, I am having back pain that doesn't feel like musculoskeletal pain exactly, and I just don't feel good. I worry that the cancer is back. My oncologist put me on the 3 month checkup regime and seems unconcerned about the bump in CA125 unless it goes up on the next 3 month checkup but I am afraid to wait. Part of me wants to find out for sure and part dreads it since I dread chemo again. I felt fantastic only a month after chemo was over...no neuropathy, no joint pain and then about 3 or so weeks ago, my joints and shins started hurting. I felt like an old woman. I thought I saw a post where you experienced something similar. My last chemo was July 14, 08. Everyone in my family keeps telling me...it's probably scar tissue or you are just paranoid. I don't know what to think. I know I am tired of constantly going back to the doctor. I am curious about the term platinum resistant. You are at one of the best cancer centers...Sloan Kettering. It is frustrating trying to decide if we get a second opinion or trust our own oncologist. I pray you get some good answers and solutions. Keep us posted.

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Actually, according to the literature a combo of gemzar+another chemotherapy (carbo?) has decent statistics on stopping the spread of the disease for a while and there is a fraction of ladies who go into remission..

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The site is called ovca.net there are such wonderful woman on this site and also on here. The one thing I must say is arming yourself with all the knowledge and talking to other woman who have gone down the same path of treatments is the best education you can get. There are acuual survivor threads with woman who have been on so many chemo regimens and are still here many years later. It is definitely inspirational to read some of their stories.
As my sister was fighting ovarian cancer she decided that she would no longer be ruled by her CA125 number. This allowed her to not be so ovelwehlmed and allowed her to go through treatments and enjoy each day. That number can be your worst enemy.
The most important thing is to live each day and enjoy your family and friends. Never give up the fight and never give up the HOPE.

Best Wishes, Elaine

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Perhaps take a look at a previous discussion on treatment of platinum resistant OVCA initiated by me
http://www.inspire.com/groups/alliance-ovarian-cancer/discussion/treatment- of-platinum-refractory-resistant-cancer/
There is quite a bit of information there graciously contributed by various people.
Yes platinum resistant statistics is not so great but maybe the fate will smile on you.. good luck! I met recently an OVCA lady who achieved a remission after being treated by the whole collection of possible chemo medicines, one after another.. finally some worked and she is 5 years after the diagnosis, in great shape.

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You just hang in there. It is not unusual to become platinum resistant. And since you go to Sloan Kettering (I also live in NYC), they know what they are doing and have access to all the latest drugs, so I'm sure you'll be fine.

I had carbo/taxol twice. The first time I got a 6 yr. remission; the second time only 10 months. I was never told I was "platinum resistant" but maybe that's what it means when there is a recurrence after 2 attemps to use it. I don't know. Carbo/taxol is considered the "gold standard" for ovca, so anything after that is not "standard" but customized to each person's situation.

I am now on Doxil. I've had 2 treatments (1 every 4 weeks) and will get tested prior to my next treatment to see how I'm doing. My doctor decided on this because even though you might get a longer remission from a combo of 2 drugs, the side effects of one drug would be less with one - but we will monitor it and change if necessary. So far, so good. He also reminded me that we are treating a "chronic disease" - so think of it that way and not as a chronic cancer.

It's hard to know which chemo to pick. All you can do is to look them up on line and try to find an understandable version of what they are. This should only be for background because your doctors should be explaining the pro's and con's of each one and you can make the decision together. I'm sure they will come up with the right combo, and remember they can change it if they results are not what they want. Try to stay calm and positive. My onc. always tells me there are plenty of drugs out there. I'm sure they will find the right ones for you.

All good wishes to you.

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RENEE-I WAS DIAGNOSED IN JULY 2006, DID THE 6 MONTHS OF IV AND IP TAXOL CARBO-REMISSION NOVEMBER 2006 WITH A CA125 OF 11 (IT WAS 1300 BEFORE MY DEBULKING SURGERY AND LIKE 150 AFTER IT) I HAD MY FIRST 3 MONTH CHECK, CA125 13. MY SECOND 3 MONTH CHECK MAY 2006, 55. I HAVE BEEN ON CHEMO SINCE. THEY CONSIDER YOU PLATINUM RESISTANT IF YOU HAVE A SHORT REMISSION, AND A SHORT REMISSION IS CONSIDERED UP TO 2 YEARS, DEPENDING ON WHO IS TALKING ABOUT IT. THE GOOD NEWS IS, AS OTHERS HAVE POSTED, THERE ARE MANY DRUGS. MY DOC CAME FROM SLOAN KETTERING, AND MCGHEE WOMENS HOSPITAL IN PA. HE WAS INVOLVED IN RESEARCH AT MCGHEE FOR OVARIAN CANCER, AND HE IS A SURGICAL, GYNO ONCOLOGIST. HE PUT ME ON CARBO GEMZAR AFTER MY RECURRANCE. 3 ROUNDS, NO PROGRESS. THEN 3 ROUNDS OF TOPETEKAN, NO PROGRESS, BUT CA125 WAS HANGING AROUND 117. SO HE TOOK ME OFF CHEMO AND ON TOMOXIFIN FOR WHAT WAS TO BE 3 MONTHS, DIDN;T WORK. JANUARY 31 OF 2008, HE STARTED ME ON NAVELBENE. MY CA125 WAS 800 WHEN WE STARTED, AND IT GOT DOWN TO 42 AT THE LOWEST. IT IS 72 NOW. I HAVE HAD TO BATTLE ASCITES, BEING DRAINED 8 TIMES THIS YEAR, WHICH IS NO BIG DEAL, AS LONG AS YOU EAT RIGHT, DRINKING OJ AND EATING PROTEIN THAT THEY DRAIN OUT OF YOU WITH THE FLUID. I HAVE FINISHED 11 ROUNDS OF NAVELBENE. I WANT SOMETHING TO MAKE THE FLUID GO AWAY, AND WE HAVE TALKED ABOUT THROWING IN AVASTIN ONCE A MONTH, BUT IT IS AN INSURANCE ISSUE THEY HAVE TO WORK OUT. SO HANG IN THERE, KEEP POSITIVE. ALSO, AFTER YOU GO 12 TO 18 MONTHS, THE PLATINUM RESISTANT CANCER CELLS LOOSE THEIR RESISTANCY IN MANY CASES. RESEARCHERS HAVE FOUND THIS, AND THAT IS WHY TAXOL AND CARBO CAN BE USED AGAIN, AFTER YOU THRU THAT LENGTH OF TIME. NO USE TO TRY IT BEFORE, THEY WANT TO SAVE IT FOR WON THE LINE, AS MY DOC ALWAYS SAYS.
ON YOUR GINGER POST. I DO LIQUID GINGER, STANDARD PROCESS, I GET IT FROM THE ALTERNATIVE DOC I SEE. TAKE A HALF TEASPOON A DAY. CAN'T HURT, AND STUDIES HAVE SHOWN GINGER TO KILL OVARIAN CANCER CELLS IN RESEARCH, SO I HAVE READ. GOD BLESS, AND KEEP THE FAITH....SHERRY

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Oh yeah, some questions I saw in some of your posts I forgot to answer,
Jenn and Favorite Aunt, platinum resistance was described to me, as recurrence within a 6 month window of your last chemo treatment. Apparently the regrowth are cells that survived and now will no longer respond to platinum chemo. Favorite Aunt, you are probably platinum sensitive given the timelines of your first remission. I am really sorry to hear it came back after 5 years...because I tell you after the 5 year mark I would have been jumping up and down not worrying anymore... Jenn... I'd doublecheck with your doc because your reasoning matches what I would think. They discovered it after 6 months, but when did it actually start?

Mom Anderson, I do not know the difference between the two, from wikipedia here is the definition of adenocarcinoma, "Adenocarcinoma is a cancer that originates in glandular tissue. This tissue is also part of a larger tissue category known as epithelial tissue." I believe epithelial covers ovarian.... he also told me mine is epithelial, but it originated in the fallopian tube. For treatment and pathology, it is the same as OvCA and usually grouped together with it.

Sherry, I hope I don't have to battle ascites. I had a "small" amount upon the discovery of my cancer the first time. I know it can be painful and I feel bad you have to get drained so often. Have you noticed an improvements in any numbers since you started ginger? I've been also taking green tea extract and curcumin, as both are supposed to work well (naturally) to prevent "angiogenisis" which is the ability of the tumor to make it's own blood supplies. I also eat one Brazil nut a day for selenium. Brazil nuts are rich in natural selenium. But I only eat one because too much selenium is bad for you from what I read.

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Hi Renee,
I, too am "platinum resistant." After IV and IP Cisplatin and Taxol, I went only 5 months before recurrence. Remission is not a word I am planning on hearing. But that's okay. I started on Doxil right away my recurrance was diagnosed. I have had 15 treatments of it (started September 07). I did get a little 3 month break to give my body and heart a rest. I am thinking right now that I will be on Doxil, until I am unable to any longer--for whatever reason, and then will move on to whatever is next. I have made the comment that Doxil is my friend. I get a little tired, a little constipated, a little chapped, but I still teach full time, and am doin' okay! I turn 54 on Monday, and have always thought that 83 is a good age to live to, and I'm still shooting for for that! I wish you the best and have already prayed for you. I remember the shell shock of hearing, "it's back, and it's not going to go away." You sound like very plucky lady! Keep on keeping on!
Carol Ann

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There is a clear relationship between platinum resistance and tumor differentiation. Poorly-differentiated tumors are, on average, significantly more sensitive to platinums than are well-differentiated tumors. The original American cooperative group trials of platinum versus non-platinum combination therapy showed that the main group of patients who benefited from platinum were patients with poorly-differentiated tumors.

Also, there is multicellular resistance, the drug affecting only the cells on the outside may not kill these cells if they are in contact with cells on the inside, which are protected from the drug. The cells may pass small molecules back and forth. A large molecule drug cannot permeate the blood-brain barrier (BBB), to give added effects to the central nervous system (CNS). However, small molecule drugs can.

Two studies reported that the drug combination of Gemzar + Cisplatin identified chemosensitivity analysis that was effective for treating women with relapsed ovarian cancer.

While both drugs are commonly used to treat an array of tumor types, the combination of these two in the treatment of relapsed ovarian cancer patients, including those with platinum resistance, was highly novel.

In the first study, researchers at Rational Therapeutics in California, investigated the results of heavily pretreated patients with relapsed ovarian cancer. The results revealed that the Gemzar + Cisplatin combination achieved a 70% response-rate, with more than 20% of the patients achieving complete remission.

Equally noteworthy was the fact that the patients whose cancer cells demonstrated sensitivity to the drug combination in the laboratory assay were the same patients who benefited the most from therapy.

They were able to achieve positive outcomes for patients, many of whom had virtually no other options, and do this by simply using available drugs more effectively.

The second study, conducted by researchers at Case Western Reserve University, Ohio, and University Hospitals of Cleveland, similarly confirmed the high response-rate for the Gemzar + Cisplatin combination in treating ovarian cancer.

These results further verify the value of drug sensitivity testing in identifying treatment options for all cancer patients who are candidates for chemotherapy. Such results could provide the basis for assay-directed therapies in a wide variety of cancers.

The Gemzar + Cisplatin combination was first identified at Rational Therapeutics and applied by Dr. Robert Nagourney in 1995 to treat heavily pretreated patients with advanced ovarian cancer. The patients, having failed all available therapies, received assay-directed therapy.

Based on the encouraging results from the two studies, a national clinical trial of the Gemzar + Cisplatin combination in treating relapsed ovarian cancer, by the Gynecologic Oncology Group, with support from the US National Cancer Institute, was instituted.

Source: Gynecol. Oncol. 88 [1], 2003

Finding The Best Treatment For Recurrent Ovarian Cancer

http://cancerfocus.net/forum/showthread.php?t=675

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Quote:
In the first study, researchers at Rational Therapeutics in California, investigated the results of heavily pretreated patients with relapsed ovarian cancer. The results revealed that the Gemzar + Cisplatin combination achieved a 70% response-rate, with more than 20% of the patients achieving complete remission.


Wow! I am bringing this up to my onc. this Friday when we talk about the game plan. 20% chance remission is much higher than the stats provided to me. I'll jump at it. (even though Cisplatin was awful for me)

My tumors were high grade (poorly differentiated) and yet they still did not respond to the cisplatin and carboplatin I had taken during therapy. I seem to not be fitting any of the averages for anything so far.

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ReneeK1. Diagnostic tests are just that, tests. Not treatment. A physician can use all the necessary diagnostic evaluations they can get. Without individualized testing, it's difficult to determine which drugs are best for patients who don't repond to certain therapies.

No data supports the superiority of any particular regimen. So it would appear that published reports of clinical trials provide precious little in the way of guidance. There are many cancer drug regimens, all of which have approximately the same probability of working.

The test doesn't change tumor biology, it reveals it. It is a reasonably good prognostic indicator for clinical outcomes with different drugs, in a disease where there is an abundance of otherwise equally-effective choices.

The tumors of different patients have different responses to chemotherapy. It requires individualized treatment based on testing the individual properties of each patient's cancer.

But as the saying goes, "don't throw out the baby with the bath water," if a drug works extremely well for a certain percentage of cancer patients (not average populations), identify which ones.

You can experiment with trial-and-error treatment or you can take the time to find the most effacious combination of drugs matched to your tumor cells. The evidence supporting a doctor's use of empiric-therapy may be less solid than the evidence supporting assay-directed therapy.

If you have any serious interest, have your oncologist call the medical director at Rational Therapeutics to further identify this protocol, and at the same time, educate him/her about the merits of cell-based assay-directed therapy, what the rationale is and what the data which support what is being considered.

http://www.rational-t.com/

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Gpaweleski, I will definitely mention it to the oncologists. But, one question, how would they get my cells, with a tissue sample taken like a biopsy? Because my doc indicated I will have no surgery this time.

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ReneeK1. Other than collecting "fresh" tumor cells obtained from surgery or "tru-cut" needle biopsies, tissue, blood, bone marrow, ascites and pleural effusions are possibilites, providing tumor cells are present, and only "live" cells can be used.

As a general rule, studies from established cell-lines (tumor cells that are cultured and maniplated so that they continue to divide) have proven to be worthless as models to predict the activity of drugs in cancer. An established cell-line is not reflective of the behavior of "fresh" tumor samples.

In other words, what works in cell-lines does not often translate into human beings. You get different results when you test passaged cells compared to primary, fresh tumors.

Paraffin embedded, fixed, minced, or frozen tissue can change over time. One gets more accurate information when using intact RNA isolated from "fresh" tissue then from using degraded RNA, which is present in paraffin-fixed tissue (preserved in paraffin wax).

At least one gram of "fresh" tissue is needed to perform the test, and a special FDA-approved kit is obtained in advance and FedExed from the lab to the medical center.

Cell-based culture methods assess the net effect of all inter-cellular and intra-cellular processes occuring in real-time when cells are exposed to anti-cancer agents. The test is performed using intact, living cancer cells plated in 3D microclusters, indicative of what will happen in the human body.

It allows for testing of different drugs within the same class and drug combinations to detect synergy and drug antagonism.

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So why the heck don't they just do them? Is is prohibitively expensive? Insurance won't pay? It's too experimental?

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Jennali. Medical oncologists select a drug or drug combination and must wait to see whether it is effective on a particular patient. Conventionally, oncologists rely on clinical trials in choosing chemotherapy regimens. But the statistical results of these population-based studies might not apply to an individual. And when patients develop metastatic cancer, it is often difficult to select an effective treatment because the tumor develops resistance to many drugs. For many cancers, especially after a relapse, more than one standard treatment exists.

Just because a drug performed best in a clinical trial doesn't mean it will work on your cancer. The laboratory test shows what drugs will work best on your cancer. Instead of prescribing drugs based on how they did in clinical trials, your treatment could be guided by chemoresponse assays. The assay test uses a sample of your tumor in the laboratory against several combinations of chemotherapy drugs. Studies show that patients who get assay-directed therapy are more likely to respond to treatment. Your oncologist will be supplied from the lab data which support what is being considered.

The assay is measuring the net effect of all processes within the cancer, acting with and against each other in real-time, and tests "living" cells actually exposed to drugs and drug combinations of interest (not theoretical predispositions). If a targeted drug could perturb any pathways/mechanisms, it is important to examine the effects of the drug combinations within the context of the cell. The key to understanding the genome is understanding how cells work. How is the cell being killed regardless of the pathway/mechanism?

In 2006, Medicare officially recognized cancer chemosensitivity tests as a special test category in Federal Regulations (42 CFR 414.510(b)(3), 71 FR 69705, 12/01/2006). They are now known as Oncologic In Vitro Chemoresponse Assays. As with all other laboratory tests in cancer medicine, the determination of the efficacy of chemoresponse assays is based on clinical correlations (comparisions of laboratory results with patient response). The "standard" of retrospective correlations between treatment outcomes and laboratory results is sufficient in the case of all laboratory tests. It is what established FDA-approval for the test kit.

Medicare made the decision that the assay is a perfectly appropriate medical service, worthy of coverage on a "non-investigational" basis (meaning it is not experimental). And what was of particular significance is that they abandoned the artificial distinction between "resistance" testing and "sensitivity" testing. Drug sensitivity testing is merely a point a little farther along on the very same continuum which resistance testing resides.

Cell-based assays based on "cell-death" have proven very effective in identifying novel treatment combinations for a variety of cancers. The value of cell-death assays is that they can and do accurately predict clinical outcomes and define novel chemotherapeutic synergies. It can help see what treatments will not have the best opportunity of being successful (resistant) and identify drugs that have the best opportunity of being successful (sensitive).

As far as costs are concerned, the test can help solve the problem of knowing which patients can tolerate "costly" new treatments and their harmful side effects. For example, Avastin costs about $50,000 for treating colon cancer, and twice as much for breast cancer (the dose is doubled). A test to identify individuals most likely to benefit from Avastin treatment cannot but cut the number of doses administered and save tremendous costs.

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