60 yo, 2.1-cm node-neg IDC, ER+/HER2-neg adj TC + AI: Systemic Tx if chest wall recurrence 2 y later and NED?
60 yo woman, s/p mastectomy for a 2.1-cm IDC, negative nodes. Patient receives TC followed by anastrozole, but 2 years after starting anastrozole a small lesion is removed from the chest wall that proves to be a recurrence. No other disease is detected clinically or on imaging. Both the primary tumor and the recurrence are ER-positive/HER2-negative. What systemic treatment would you recommend?
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Kimberly L Blackwell, MD |
| Professor of Medicine Director, Breast Cancer Program Duke Cancer Institute Durham, North Carolina |
Exemestane + everolimus
Data from the CALOR study demonstrated a benefit with adjuvant chemotherapy for patients who experienced a local or regional recurrence. Hence my recommendation would be 4 cycles of AC/paclitaxel. I would follow that with 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 |
This is a difficult decision. The CALOR trial that studied the effect of adjuvant chemotherapy for patients with local/regional recurrence showed a bigger benefit for the ER-negative group of patients than the patients with ER-positive disease. A longer follow-up is needed to determine the effect on the ER-positive subgroup. I would have a conversation with the patient who developed a recurrence in the chest wall about additional therapy and would lean toward treatment with AC or CMF.
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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 |
I would change endocrine therapy because the patient has experienced relapse on anastrozole after only 2 years. I would favor tamoxifen, so she will not have to receive monthly shots with fulvestrant. The CALOR trial demonstrated a benefit with adjuvant chemotherapy for patients with a local or regional recurrence of breast cancer. The benefit in the ER-positive setting was not as impressive as the benefit for the ER-negative subgroup. But chemotherapy with capecitabine would be a consideration.
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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 |
The recurrence has occurred after a relatively short period of time, and the tumor is likely to be refractory to conventional therapy. I would recommend another course of adjuvant chemotherapy. Because the patient had previously received TC, I would opt for CMF or doxorubicin-based treatment. I would also change her hormone therapy.
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Ian E Krop, MD, PhD |
| Associate Physician Dana-Farber Cancer Institute Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts |
tam
Based on the CALOR data,I would offer this 60-year-old patient who developed a chest wall recurrence 2 years after adjuvant treatment doxorubicin/cyclophosphamide followed by tamoxifen.
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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 change the endocrine therapy for a patient who developed a recurrence in the chest wall.
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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 |
fulvestrant
My recommendation for a 60-year-old patient who experienced a recurrence in the chest wall 2 years after starting anastrozole would depend on the tumor biology. I would consider how highly proliferative and how strongly ER/PR-positive the tumor was. If it was a highly proliferative ER-positive tumor, I would offer the patient nab paclitaxel/capecitabine for 6 months, followed by fulvestrant.
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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 change the endocrine therapy a patient was receiving if she developed a recurrence in the chest wall 2 years after starting anastrozole.