Case Study: Treating HER2-Positive MBC, Part I

Panelists: Adam M. Brufsky, MD, PhD, University of Pittsburgh; Sara Hurvitz, MD, UCLA;
Joyce A. O'Shaughnessy, MD, US Oncology; Edith A. Perez, MD, Mayo Clinic; Hope S. Rugo, MD, UCSF;
Andrew D. Seidman, MD, MSKCC
Published Online: Wednesday, August 14, 2013
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Moderator, Adam M. Brufsky, MD, PhD, presents a case study that examines a 59 year-old woman presenting with fatigue and dyspnea approximately 8 years following her initial treatment for breast cancer. At this first presentation, the patient was diagnosed with stage I, hormone receptor positive, and HER2-positive breast cancer. At this point, her treatment included adjuvant Adriamycin plus Cytoxan followed by paclitaxel with trastuzumab and finally the administration of anastrozole for five years.

At the 8-year follow-up, the fatigue and breathlessness led to a CT scan of the chest, abdomen, and pelvis, explains Brufsky. This examination identified pulmonary metastases, the largest of which was 2 cm. Additionally, multiple liver metastases were noted, with the largest measuring approximately 4 cm. However, liver function testing was normal. A liver biopsy confirmed estrogen receptor-positive disease that was also HER2-positive by FISH with a ratio of approximately 2.3, Brufsky notes.

Assessing disease burden and symptoms is the first step in the frontline setting for a patient with metastatic breast cancer that is both ER and HER2-positive, believes Sara Hurvitz, MD. In this case, the patient presents with an indolent tumor and may benefit from treatment with the combination of a hormonal and HER2-targeted agent. As a result, Hurvitz recommends the administration of a taxane with pertuzumab and trastuzumab in the frontline setting for 6 cycles or until a response reduces symptoms. After this point, treatment can be transitioned to HER2-targeted therapies alone with the potential to add an endocrine therapy.

The panel agrees with this treatment approach and transitions the discussion toward HER2 testing, specifically the ratio of HER2 to chromosome 17. The initial ratio of 2.3 is not very high but is adequate to label the disease as HER2-positive, believes Edith A. Perez, MD. Studies have indicated that the degree of HER2 amplification does not impact the efficacy of targeted therapies, such as trastuzumab. As a result, even a patient with a lower ratio for positivity should still receive HER2-targeted therapy.

Further complicating testing, heterogeneity is present in approximately 10% of patients with HER2-positive breast cancer. As a result, guidelines now recommend dual testing for patients with breast cancer to verify the findings, Perez states. Another approach for identifying HER2-positivity measures the number of HER2 gene copies. This approach may provide additional accuracy, when considered along with the ratio, believes Joyce A. O'Shaughnessy, MD.

View More From This Discussion
Episode 1 Introduction and Exploration of Fulvestrant in Breast Cancer
Episode 2 Combination of Anastrozole and Fulvestrant in MBC
Episode 3 BOLERO-2 Trial: Everolimus in Metastatic Breast Cancer
Episode 4 Management of mTOR Inhibitor Side Effects in Breast Cancer
Episode 5 EMILIA Trial: T-DM1 in Metastatic Breast Cancer
Episode 6 Frontline T-DM1 in HER2+ Metastatic Breast Cancer
Episode 7 CLEOPATRA Trial: Frontline Pertuzumab for HER2+ MBC
Episode 8 MA.31 Trial: Taxane With Lapatinib or Trastuzumab
Episode 9 Treatment With Eribulin in Metastatic Breast Cancer
Episode 10 Case Study: Treating HER2-Positive MBC, Part I
Episode 11 Case Study: Treating HER2-Positive MBC, Part II
Episode 12 Paclitaxel With Pertuzumab Plus Trastuzumab in MBC
Episode 13 Case Study: Treating HR+ and HER2- Breast Cancer
Episode 14 Managing Bone Health in Metastatic Breast Cancer
Episode 15 Surgical Removal of Primary Tumors in Stage IV MBC
Episode 16 Case Study: Metastatic Triple-Negative Breast Cancer
Episode 17 Personalized Medicine in Triple-Negative Breast Cancer
Episode 18 Conclusion and Final Thoughts on Managing Breast Cancer
Expert Panelists
Dr Adam Brufsky

Adam M. Brufsky, MD, PhD

Professor of Medicine, University of Pittsburgh
Medical Director of the Women’s Cancer Center
at Magee-Womens Hospital of UPMC
and the University of Pittsburgh Cancer Institute
Pittsburgh, Pennsylvania

Sara Hurvitz, MD

Assistant Professor & Director,
Hematology/Oncology Breast Cancer Program, UCLA's Jonsson Comprehensive Cancer Center, Los Angeles, California

Joyce A. O’Shaughnessy, MD

Co-Director, Breast Cancer Research
Baylor Charles A. Sammons Cancer Center
Texas Oncology, PA/US Oncology,
Dallas, Texas

Edith A. Perez, MD

Deputy Director of the Mayo Clinic Cancer Center, Director of the Breast Cancer Translational Genomics Program and the Breast Program at Mayo Clinic,
Jacksonville, Florida

Hope S. Rugo, MD

Professor of Medicine and Director of the Breast Oncology, Clinical Trials, and Education Program, University of California San Francisco Comprehensive Cancer Center, San Francisco, California

Andrew D. Seidman, MD

Professor of Medicine, Weill Cornell Cancer Center, Attending Physician at Memorial Sloan Kettering Cancer Center,
New York, New York
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