DR HURVITZ: She received first-line letrozole with bisphosphonate, had disease control for 6 months, and then went on second-line capecitabine for 8 months, at which time she developed liver metastases. Then we put her on fulvestrant. She had disease control for another 8 months and then had, again, progression of her disease in the liver and now is beginning to have some decline in her liver function and wasn’t feeling well and wanted some time to travel with her husband and be with her grandchildren, so was willing to do a little more but adamantly refused taxanes and anthracyclines.
DR LOVE: We all know there are many potential options. But just very briefly I’d like to go around the table again, and tell me your thoughts about what you’d be thinking about in terms of what you might want to do. Let’s start with Hope.
DR RUGO: I might discuss with her use of liposomal doxorubicin. No hair loss, very well tolerated in most patients, if you don’t use a really high dose or in combination, and can be managed as once a month or even every 5-week infusions, depending on how patients clear the drug. I think that that would be potentially my first choice.
DR LOVE: Lisa?
DR CAREY: I have a slightly different reaction to a patient like this, who I think is saying, “I’m putting my quality of life up front. This is incurable, so in a sense everything you’re doing is palliative.” She’s asymptomatic with some declining liver function. You can tip her over pretty quickly if you’re not careful. I probably would thread the needle with something I really didn’t think would get her into trouble and go to exemestane or go back to tamoxifen. I mean, if she was willing to assume some risk in terms of toxicity, you could add everolimus or you could go a chemo route.
What I was hearing in the story was a patient who is putting quality of life on an equal if not higher basis than efforts at prolonged disease control.
DR LOVE: Edith?
DR PEREZ: I actually think that the statements by both Hope and Lisa bring up very interesting issues. I think even exemestane in combination with everolimus could be an interesting idea for this particular patient. That I would really consider.
DR LOVE: Adam?
DR BRUFSKY: The nice thing about everolimus is that it’s been used in hepatic transplantation, so we know how to give it in liver — there’s all sorts of dosing adjustments that we give, that have all been worked out. All the pharmacokinetics have been worked out in the transplant literature. And there’s a very nice dosing schedule they have for her. I think that would be my first choice.
DR LOVE: We just talked about a study looking at eribulin versus capecitabine. What about eribulin in somebody like this?
DR BRUFSKY: Eribulin would be fine.
DR LOVE: Ruth?
DR O'REGAN: I would definitely push for endocrine therapy and everolimus. Start her on it and, if she couldn’t tolerate it, just leave her on exemestane alone, let her do her traveling. I think all the comments about the chemotherapy are well taken. Doxil would be a very good choice for her. I think if I was going to use a taxane, I’d probably, rather than using eribulin, would use weekly paclitaxel or something because she’s never had a taxane before. But, again, obviously her quality of life is very important and we can’t cure this disease, so we have to let her go about her business as much as she can.
DR LOVE: So what happened, Sara?
DR HURVITZ: After a long discussion and her view of multiple papers — she was very educated — she chose to go on eribulin. We gave her 2 cycles and she had a remarkable response in her liver. The only dose limiting or dose delays were due to neutropenia, which I find is the major problem with eribulin. Ultimately, she was able to enjoy 7 more months with good disease control on eribulin. After eribulin, she did receive everolimus-based therapy. But she was able to do the travel and do those things in that time.
DR LOVE: Everolimus with…? And what happened?
DR HURVITZ: With exemestane. She had disease control for about 6 months.
DR LOVE: Any toxicity?
DR HURVITZ: Yeah, stomatitis. Stomatitis was a real problem with her. We had to hold the therapy several times.