DR RUGO: I think that there are a couple of issues with that trial. It was an unselected trial, as many of these are in the metastatic setting. But we know that capecitabine is a very effective drug for patients with ER-positive disease. We’ve been talking about how we often use that in the first-line chemotherapy approach. So you have a patient who has anthracycline- and taxane-pretreated cancer. Some of these patients respond for a long duration to capecitabine and tolerate it very well.
The trial didn’t show any difference between the 2 drugs, although what they did show, which is interesting, is in the subset of patients who have triple-negative disease who may have disease that’s relatively less sensitive to capecitabine, that eribulin might have been a little bit more effective. I think that where that leaves us is not that necessarily one drug is better than the other. I think it’s that we don’t know that the order makes any difference. And so we should be using our drugs in sequence, choosing the least toxic drugs for our patients earlier in settings where we don’t know that one is better than another.
DR LOVE: I’m curious, though. I heard what seemed like disappointment about this, that eribulin wasn’t better, but I think capecitabine is a pretty good drug. And to see kind of equivalent side effects/toxicity and efficacy to me provides another option to patients. Lisa, what are your thoughts about the paper, and where does eribulin fit in your algorithm?
DR CAREY: I have to say I had a similar reaction, which was that this was not a disappointment. This was moving a drug that we all have become comfortable with in the very late-line setting to an earlier setting. And if it is as good as a good drug, then it is another option in the essentially mostly second-line setting — there were a few in the first-line setting — with a totally different toxicity profile.
In the metastatic setting, you’re going to be using a variety of drugs over the course of the patient’s life. And you’re going to be choosing on a patient-to-patient basis on the basis of, for example, GI toxicity versus neuropathy. And this is another option. I actually found it to be a useful study and one that helps with practice.
DR RUGO: A positive trial.
DR CAREY: Yeah.
DR LOVE: Final comment about this from Adam. I’m curious how you see this trial in terms of, also, the role of eribulin.
DR BRUFSKY: This is metastatic breast cancer. Most women are probably going to get both drugs at some point in their disease course, so it doesn’t really matter where you use it. Whether someone wants an oral drug, where they don’t want to lose their hair, where they want to come in for IV. I mean, these are the sort of decisions that we make. I think that most of us, I would say, if you took a poll of all of us sitting here, I don’t think that order matters. I mean, maybe it does, but we don’t have enough data to guide us one way or the other about the order or which way we give these things.