Tx PMW ER+/HER2-neg, asymptomatic mets after 3 years adj AI?
What would you generally recommend for a postmenopausal patient with ER-positive/HER2-negative disease with asymptomatic, higher-volume metastases after receiving adjuvant anastrozole for 3 years?
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Kimberly L Blackwell, MD |
| Professor of Medicine Director, Breast Cancer Program Duke Cancer Institute Durham, North Carolina |
If a patient in this situation presented with asymptomatic metastases 3 years after adjuvant therapy, I would recommend changing the endocrine therapy to exemestane and combining it with everolimus. For me the decision is not so much whether to administer chemotherapy but whether the patient would benefit from endocrine therapy after 3 years. I believe it is reasonable that she would. I would also consider fulvestrant at the 500-mg dose as an option. I would be in favor of retesting ER expression to determine why she experienced relapse on endocrine therapy.
If the patient developed symptomatic disease recurrence 3 years after starting adjuvant treatment I would recommend exemestane and everolimus.
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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 |
If a patient presented with metastases 3 years after adjuvant therapy, I’d be concerned about the possibility of acquired resistance. So I would consider an everolimus-based regimen with exemestane. My approach would be the same if this patient experienced symptomatic disease recurrence 3 years after adjuvant therapy.
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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 |
If a patient presented 3 years after receiving adjuvant therapy, because she fared well on anastrozole for a long time, it is unlikely that I would add everolimus. I would recommend fulvestrant or tamoxifen alone in this scenario.
If the patient developed symptomatic metastases 3 years after adjuvant therapy, I’d administer chemotherapy followed by fulvestrant or tamoxifen. I would hold off on the exemestane/everolimus.
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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 |
I would offer exemestane and everolimus if a patient presented after 3 years of adjuvant therapy. I would be a little more optimistic about hormone therapy being effective in this scenario than I would if the patient had presented after only 1 year of adjuvant therapy.
For a patient who was symptomatic 3 years after adjuvant therapy, I would lean toward everolimus/exemestane.
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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 likely administer 500-mg fulvestrant to this asymptomatic patient if she presented 3 years after receiving adjuvant anastrozole. I tend to reserve everolimus/exemestane for patients with symptomatic disease given this regimen’s less favorable toxicity profile compared to hormonal therapy alone.
For a patient with symptomatic metastases 3 years after adjuvant therapy, I would suggest chemotherapy and, if she had a good response, follow that with fulvestrant. With a patient who is symptomatic, I would opt for chemotherapy because it has a significant chance of cytoreducing her cancer so that her symptoms improve. I prefer hormone therapy whenever possible because it is better tolerated than 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 3 years after receiving adjuvant anastrozole with asymptomatic disease because I think the toxicity profile of fulvestrant is favorable compared to that of everolimus.
I would also recommend fulvestrant for a patient who had symptomatic disease 3 years after adjuvant therapy.
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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 3 years after adjuvant treatment on anastrozole, I would rebiopsy the tumor to confirm that it remains ER-positive, and then I would elect to administer exemestane and everolimus.
My recommendation for a patient who presented with symptomatic disease 3 years after adjuvant therapy would depend on where the disease is located and how symptomatic the patient is. Generally, if a patient is highly symptomatic, I will administer chemotherapy. I would use nanoparticle albumin-bound (nab) paclitaxel/capecitabine for this patient.
Because the patient has been receiving 3 years of adjuvant endocrine therapy, the tumor may have some degree of endocrine sensitivity. Most of the patients who benefited from exemestane/everolimus in the BOLERO-2 study had disease that was endocrine sensitive. However, I would like to give her the benefit of the doubt and treat with chemotherapy with the thought that I could administer exemestane and everolimus after chemotherapy.
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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 |
For a patient who presented with asymptomatic metastases 3 years after adjuvant therapy, I would recommend everolimus and exemestane.
My recommendation for a patient who presented with symptomatic disease 3 years after adjuvant therapy would depend on whether the disease was visceral or nonvisceral. I would administer chemotherapy to a patient who has visceral disease and organ dysfunction to obtain a rapid response. If the metastases were limited to the bone, I might not opt for chemotherapy.