DR BRUFSKY: So this is a 60-year-old woman with metastatic breast cancer to the iliac crest and sternum. She was diagnosed about 14 months ago. We treated her with 12 months of anastrozole and, at restaging CT, she now has 2 small liver metastases, the largest of which is 1.5 centimeters. She’s asymptomatic. And so the question for everybody here is: What’s the next therapy?
DR LOVE: Ruth, any thoughts about how you might think this through?
DR O'REGAN: I would probably actually consider just going with another line of endocrine therapy — probably something like fulvestrant, see how she did with that at the higher dose. I don’t think we know where to use everolimus right now. So she does definitely meet criteria for that, but I might save that for later on.
DR LOVE: Bill?
DR GRADISHAR: She’s got multiple options, including what Ruth suggested, as well as adding an mTOR inhibitor to a steroidal AI, even tamoxifen. I mean, this is somebody who could get tamoxifen as well. There are a number of different options.
DR LOVE: Sara?
DR HURVITZ: I agree with what the others have said. I would not initiate chemotherapy based on this good response initially. I agree with the fulvestrant. I might, however, have used exemestane and everolimus. It’s the new kid on the block, and I have a fair amount of experience using it. But I don’t disagree that fulvestrant is less toxic in many situations and would be an equally good or even better choice. I know my knee-jerk reaction in the clinic may have been to discuss exemestane and everolimus.
DR LOVE: Hope?
DR RUGO: She’s an interesting patient because of the de novo metastatic situation, but in this particular patient, she did have 12 months on anastrozole. But during that time, she grew 2 liver metastases. So you figure it’s a little shorter than that, really, and it has to do with when you do your scan. So I would be more inclined, actually, to use an everolimus combination now because the patient has liver metastases. And I feel like that’s the beginning of, for most patients, a kind of slope toward more rapid progression to chemotherapy. And I think the major issue we’re all concerned about, other than cost, is that these patients have more toxicity from the addition of everolimus.
DR LOVE: Lisa, how would you be thinking about managing this lady?
DR CAREY: I have to say I’m struck by a long time of disease control in choosing these things. And in an asymptomatic patient with 2 small liver mets, I would give another run at an endocrine therapy. I think she does actually fit very well with the studies where everolimus did improve outcome. I take a slightly different tack. I share the concerns about toxicity. I tend to start it and then see how it goes, and then I’ll reduce it or stop it if the patients run into toxicity that I can’t manage.
DR LOVE: Edith?
DR PEREZ: Two considerations in this patient: Number one, compliance to the anastrozole. Because I think this is kind of a hidden problem we probably should pay more attention to, as certainly in the adjuvant setting, studies have shown that about 20% of patients within the first year are not taking their medication as prescribed. So this is something to ask the patient before we move to change medication. Is she taking the anastrozole as prescribed? If the answer is no or yes, then we can act on that.
Originally, I would have thought about fulvestrant, but based on the EFECT trial with the lower dose of fulvestrant, the data with fulvestrant were not that good in terms of progression-free survival, as Bill knows and other people. But now that we have the data with the higher dose of fulvestrant, I’m really impressed, based on the CONFIRM trial, of the activity of higher doses of fulvestrant for patients with ER-positive disease.
DR LOVE: Adam?
DR BRUFSKY: This is the kind of case where a year ago the choice would have been fulvestrant. But I agree. I mean, the EFECT data is not great. It’s 4 months of PFS in this sort of situation. The real choices would have been fulvestrant, tamoxifen, old tried and true. I would have used a lot of tamoxifen in someone like this. I think the big issue that would have worried my colleagues in the community would have been the liver mets. I think a lot of people get concerned when you have visceral disease and they kind of want to think about chemo. I think capecitabine is a big one. I think that would have been the other choice a lot of us would have done.
But this is somebody who I actually did use exemestane and everolimus on. I think that our practice and our group in Pittsburgh is really moving toward that in our guidelines as the second-line therapy.
DR LOVE: How long has she been on it, and what’s going on?
DR BRUFSKY: She’s been on it for about 2 1/2 months. I use tumor markers, which is very controversial. We can talk about that later. But her CA27.29 went down. Her liver mets, we just recently staged her. Her liver disease is now a little bit better, maybe like 0.8 centimeters. It was a large metastasis. The biggest side effects of these drugs that I’ve run into are, again, the mucositis. I mean, I think clearly the mucositis is, as they say, about 10%, and it can be fairly severe.
What I generally do when that happens is, instead of going down to the 5-mg dose, I do something that’s not exactly in the label. I might as well say that because this is CME. What I do is give the drug every other day. It has a long enough half-life that it’s a cheaper way of doing it actually. The patient already has the pills — doesn’t have to spend it again.
DR PEREZ: Mm-hmm.
DR BRUFSKY: And in fact, I get away with that. So, I do 10 mg every other day in a couple of patients. In this lady, I didn’t have to. She actually did pretty well.
DR LOVE: So she had no mucositis?
DR BRUFSKY: She had no mucositis, no rash.
DR LOVE: Interesting.
DR BRUFSKY: Which are really the big ones in my practice.
DR LOVE: Interesting.