Second line Therapy

Following treatment with Alimta and Cisplatin you may have a respite period until your tumor begins to once again become active.  This is the time to explore second line therapy.  There are many drugs and combinations of drugs that have demonstrated some activity in mesothelioma but have not been studied in large enough numbers to get FDA designation as approved second line therapy.

Insurance companies can deny these therapies but in many cases will permit treatment once a denial followed by an appeal process takes place.  Each insurance plan is different but it usually is a multi step process that takes place over a few weeks which though creating much anxiety and angst can in most cases be resolved.  If you have completed you initial treatment and are in the “watch and wait phase” then you have the time to explore the next treatment option.  There are a number of clinical trials available as second line and we should discuss them together as there are factors that make you eligible or ineligible for these trials. Second line therapies that are not part of a trial can be used at any time but Phase II studies usually require that you have failed one standard regimen and sometimes will disqualify you if you have had additional treatments so it is important to get this right and leave as many options open for future needs. If your tumor has progressed and you need to seek immediate treatment be assured that a new treatment will not be introduced until you are one month out from prior treatment.  This is required as we want patients to have a resolution of toxicities from the prior regimen so there will be no confusion as to what side effects have been induced from which agent.  You will need a new work up which usually includes labs and scans and if on protocol you might have some protocol specific testing as well.

Scans are planned close to the time of the start of your new regimen so measurements can be obtained for future comparison.   If on a clinical trial with a new agent not yet approved for cancer you will be given the drug at no cost but will incur costs associated with what is considered standard of care.  This should all be discussed with you at the time of the consent process.  You have a right to know your financial obligations and should insist and a full disclosure of what to expect.  If you are having financial difficulty then you should schedule an appointment with an out patient oncology social worker.  They are trained to discuss insurance issues, help you identify organizations that provide financial assistance, network with pharmaceutical companies to help you obtain free or discounted drugs if you qualify.  This is a valuable resource as is your case manager at the insurance company.  Ask your health insurance company to assign a case manager to you.

This person once identified should become familiar with your care and often assists in an appeals process should you have treatment or testing denied. This is done in conjunction with your physician’s office.  They are used to the appeal process and know the correct wording to assist in getting approval.  Do not try to do this on your own as it can lead to further blocks.  Look into what plans are offered and be prepared if necessary to make a change during your company’s open enrollment time.  If you are on Medicare explore what options are available including AARP which gets high approval ratings from many on this site.  They have some great plans to supplement your existing policies.  Medicare has a help center where you can directly ask questions pertaining to your coverage….and beware of Medicare HMOs they tend to be very restrictive so explore them carefully before you sign on.  With all of this in mind you should be ready to explore the various treatment options.

~Mary Hesdorffer, NP