20th August 2019

Take a second look: The importance of rebiopsying

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As we know, lung cancer is tricky. Treatment can be working well, but then the tumour may develop ways to resist the therapy and starts to grow again. This can be very discouraging for patients and their loved ones. However, with advances in treatment coming thick and fast, that ‘turning point’ could open the door to a new approach.

We spoke to two experts – our senior research fellow at the University of Liverpool, Dr Mike Davies and consultant respiratory physician with Newcastle Upon Tyne Hospitals NHS Trust, Dr Simon Doe – to outline this process and its implications.

“As a cancer grows, it adapts to its surroundings, evolves and spreads,” explains Dr Davies.

“This means, when we treat cancers with drugs or radiotherapy, some of them can develop so that the therapy stops working and, rather than shrinking, the tumour starts to re-grow.

When this happens, we may rebiopsy the tumour to try to determine how the cancer has evolved, by looking for new mutations in the tumours DNA.

Results from the rebiospy may give us the opportunity to offer a more effective therapy, one that might not have been suitable originally.”

This is exactly what happened to Kathy Beattie, from Halesowen near Birmingham, who was diagnosed with lung cancer in June 2013.

An initial biopsy confirmed Kathy had stage 4 lung cancer and she was given chemotherapy. It seemed to be working; scans showed the tumour had shrunk. However, a few months on, Kathy received the devastating news that the cancer had started to grow again:

Kathy has been living with stage 4 lung cancer since 2013

“I was told there was no alternative but more chemo. That was when I decided to speak out and start asking questions. My husband always said talking is one of my favourite things, so it was about time I put it into practice!

I asked if there were any clinical trials and found out there was. I had a lung biopsy to see if I was eligible.

The biopsy revealed two mutations – PDL1 and EGFR. You may not know what they mean but they were my golden treatment ticket. I didn’t need to go on the trial – I could have a targeted therapy called erlotinib (Tarceva®) which I was on for 20 months.

Once again however, a scan showed progression in my spine and pelvis. It sounds bad, and whilst it certainly wasn’t good, I still had options. I was given a different targeted therapy, rocilitinib. I called it ‘Rocky’ and it was tough like the boxer – but on me rather than the cancer. My blood sugar levels were through the roof; I had to take metformin to bring them down. It was also really hard on my tummy; I didn’t leave the house for six weeks.

I had to take charge of the situation. I rang my oncologist, Professor Dean Fennell, and told him the effect the treatment was having on me. I had no quality of life and so I refused to take it anymore.

Professor Fennell suggested I have another biopsy and this time there was good news; I was eligible for a new targeted therapy called osimertinib (Tagresso®). For me, it has been a dream come true. I have few, minor side effects. The drug is keeping the cancer in check and, just as importantly, it has given me my life back.

The new types of treatments are leading to significantly better results where people are well and living longer. As a result, there are occasions when it’s a good idea for us to think about revisiting a tumour, to consider taking a second biopsy.

Dr Simon Doe, Newcastle Upon Tyne Hospitals NHS Trust,

I have loads of energy and an incredible social life. I have had to give up work but with a jam packed social calendar, I don’t know how I’d fit it in now anyway!

I know my current treatment will stop working, and while that’s scary, I also know new treatments are there with even more coming. I may be able to have immunotherapy, or even a combination of drugs.

I only know this because I became my own advocate. No one wants you to live more than you so make it your responsibility to know every option there is. Don’t be afraid to ask questions or to challenge your doctors. If your treatment stops working, ask for a rebiopsy. It might show you can have a new kind of treatment.

I always said I was diagnosed at the right time. It’s amazing how fast everything is moving – we are so lucky to be living in this age. My lung cancer may not be curable but that doesn’t mean it isn’t treatable. It doesn’t mean it isn’t liveable. Trust me, it is.”

Dr Doe broadly shares Kathy’s optimism.

“For a long time, there has been a certain degree of nihilism about managing lung cancer. Too often people are diagnosed at a stage when it is not curable and previous treatments have not been as effective as we’d like, or as effective as for other types of cancer.

Now, however, the new types of treatments are leading to significantly better results where people are well and living longer. As a result, there are occasions when it’s a good idea for us to think about revisiting a tumour, to consider taking a second biopsy.

For instance, if someone has had a course of chemotherapy and there are signs that the tumour is starting to grow again, we are increasingly recommending that a further biopsy be considered. We can then see whether there has been a change in the nature of that tumour.

Changes may mean that different treatment should be considered. Sometimes those changes can be along a more traditional route, so, for instance, tumours can go from being a more squamous type to an adenocarcinoma type, which would require different types of chemotherapy.

But more often, we’re now looking for different, newly-discovered genetic changes in the tumours that mean that some treatments targeted at that genetic change are more likely to be beneficial.

There is still a long way to go but I do think we are on the right road towards much better and more effective treatments.”