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Rounds with the Investigators 2012 | Breast Cancer

DR LOVE: The other case, Beth — a patient diagnosed with triple-negative, 2 nodes positive in 2010, a premenopausal lady. Doesn’t say what the age was. She gets FEC/T, radiation therapy, but then a year later is diagnosed — this is 12/2011 — with mets to the chest wall, internal mammary nodes, sternum, liver, lungs and bone. She gets treated with gemcitabine/cisplatin and bevacizumab, has a good PR, and that’s where she is right now.

The question about this case is, should the gem/cis/bev be continued given that it’s currently stable, or should there be consideration to switching to capecitabine monotherapy? Any thoughts about that?

DR BETH OVERMOYER: First I would just make sure that she is tested for BRCA. I mean, she only has a 20% chance, but it certainly may impact on therapies down the line. So that I would make sure.

DR LOVE: BRCA2-positive. Sorry.

DR OVERMOYER: Okay. So in the future, think of PARP inhibitors for her.

DR LOVE: That was the other question about that for her.

DR OVERMOYER: Oh.

DR LOVE: That in addition to the question of should the chemo be switched, what about a PARP inhibitor trial?

DR OVERMOYER: I think a PARP inhibitor trial would be very good for her. I think that consistently, in all of the PARP inhibitor studies, it’s the patients who have the BRCA mutation that have been found to be — that it’s been found to be beneficial. And so I think that if she can get on a PARP inhibitor trial in the future, that would be great.

I think that the data nowadays suggests that you should keep people on the chemotherapy for longer than we used to. So as long as she’s tolerating it, I would keep her on the drug. Stable disease is still not progression. And depending upon her tolerance, obviously, those drugs can be peeled off one at a time.

But I would not switch her chemotherapy unless she progresses, because given her disease a year later, triple-negative, she doesn’t have a lot of options. And I would hold off on any therapy until she progresses.

DR LOVE: So just to clarify, though — because we haven’t heard much about PARP inhibitors lately — Chuck, do you agree with the statement that responses are seen with BRCA-positive breast cancer to PARP inhibitors?

DR CHARLES GEYER: Oh, yes. No. I mean, I think that patients with BRCA mutations who develop breast cancer, that the cancers are sometimes — it’s an active agent. I mean, again, I have all these anecdotes, angry insurance company anecdotes. I had a patient that came to me that had been heavily pretreated, triple-negative. She was young, so I said, “Oh. Let’s just check.” Boom. She had a mutation. And they were doing a study of I think it was paclitaxel with one of the PARP inhibitors across the street at Pitt. And I thought, “Great. I would put you on the paclitaxel. This is free.” Her insurance company would not pay for the chemotherapy if she was also getting the PARP inhibitor. They would pay for it without the PARP inhibitor.

This was discovered after she was on the PARP inhibitor, responding. She had to stop the study. And the moment she did — progressed.

DR LOVE: Wow!

DR GEYER: Worst story — it still drives me just — I go crazy. And I got an email she passed away last week. Just insanity, absolute insanity.

DR LOVE: I’ve got to say, I hear things every day I’ve never heard before, but I have heard that before, actually: Patients who are responding and while they’re responding have insurance denied for the drug that’s actually working.