Tx PMW ER+/HER2-neg, asymptomatic mets after 1 year adj AI?
What would you generally recommend for a postmenopausal patient with ER-positive/HER2-negative disease with asymptomatic, low-volume metastases after receiving adjuvant anastrozole for 1 year?
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Kimberly L Blackwell, MD |
| Professor of Medicine Director, Breast Cancer Program Duke Cancer Institute Durham, North Carolina |
I would administer exemestane and everolimus for a postmenopausal woman who developed ER-positive asymptomatic metastases because she is experiencing relapse after 1 year of anastrozole therapy. I would recheck her ER status because the early relapse is not typical of truly ER-positive breast cancer. I believe it’s the clinician’s job to determine the reason for the early relapse. My guess is that the patient could have PR loss, which is a poor prognostic factor, or more commonly low ER expression. I would use that information to inform my decision about starting chemotherapy.
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Lisa A Carey, MD |
| Richardson and Marilyn Jacobs Preyer Distinguished Professor for Breast Cancer Research Chief, Division of Hematology and Oncology Physician-in-Chief North Carolina Cancer Hospital Associate Director for Clinical Research Lineberger Comprehensive Cancer Center Chapel Hill, North Carolina |
I would administer fulvestrant to this postmenopausal woman who is asymptomatic and has ER-positive metastatic breast cancer. I would not consider a patient in this scenario to have acquired endocrine resistance.
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Julie R Gralow, MD |
| Professor, Medical Oncology Jill Bennett Endowed Professorship in Breast Cancer University of Washington School of Medicine Director, Breast Medical Oncology University of Washington School of Medicine/Seattle Cancer Care Alliance Member, Clinical Research Division Fred Hutchinson Cancer Research Center Seattle, Washington |
For the asymptomatic patient who has experienced relapse after only 1 year of endocrine therapy, I’m concerned about endocrine resistance. Hence I would lean toward administering exemestane/everolimus. However, I would be worried about the extra toxicity of everolimus. So, depending on the patient’s age and the extent of disease, I might hold it. I believe it would be reasonable to consider one more shot at endocrine therapy with fulvestrant or tamoxifen alone.
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Clifford Hudis, MD |
| Chief, Breast Cancer Medicine Service Solid Tumor Division Department of Medicine Memorial Sloan-Kettering Cancer Center Professor of Medicine Weill Cornell Medical College New York, New York |
Because the patient has experienced an early relapse and presents with asymptomatic, low-volume metastatic disease I would recommend exemestane and everolimus. The fact that she is asymptomatic is a big motivation for me to give her one more shot at hormone therapy. If she becomes symptomatic in 8 to 12 weeks, I would then start her on chemotherapy.
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Ian E Krop, MD, PhD |
| Associate Physician Dana-Farber Cancer Institute Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts |
I would generally administer hormone therapy with fulvestrant at the 500-mg dose to this patient who has asymptomatic metastatic disease. My general recommendation is hormonal therapy whenever possible, because it is better tolerated than most chemotherapy.
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Kathy D Miller, MD |
| Co-Director, IU Simon Cancer Center Breast Cancer Team Ballvé Lantero Scholar in Oncology Associate Professor of Medicine Department of Personalized Medicine Division of Hematology/Oncology The Indiana University Melvin and Bren Simon Cancer Center Indianapolis, Indiana |
I would recommend 500-mg fulvestrant for a postmenopausal patient if she presented 1 year after receiving adjuvant anastrozole with asymptomatic, low-volume metastases. I administer fulvestrant to asymptomatic patients because the toxicity associated with everolimus is not inconsequential.
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Joyce O’Shaughnessy, MD |
| Co-Director Breast Cancer Research Program Baylor-Charles A Sammons Cancer Center Texas Oncology US Oncology Dallas, Texas |
If a patient experienced recurrence 1 year after adjuvant treatment on anastrozole, I would rebiopsy the tumor to verify that it’s not HER2-positive and remains ER-positive. I would administer exemestane and everolimus to this patient because she experienced relapse while receiving anastrozole.
Results from the BOLERO-2 study showed that treatment with exemestane alone was not beneficial, with a median progression-free survival (PFS) of about 3 months. Patients experienced a much longer PFS with the addition of everolimus to exemestane.
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Hope S Rugo, MD |
| Professor of Medicine Director Breast Oncology and Clinical Trials Education University of California, San Francisco Helen Diller Family Comprehensive Cancer Center San Francisco, California |
I would consider exemestane with everolimus in this scenario. This patient has a poor prognosis even with low-volume disease because she has developed new metastases only 1 year after adjuvant therapy. I would also strongly consider evaluating the patient for a clinical trial. A lot of good trials are investigating the addition of targeted agents that would be extremely promising for patients with progressive disease.