Combination of Anastrozole and Fulvestrant in MBC
Published Online: Monday, June 10, 2013
For High-Definition, ClickSelecting the optimal treatment for postmenopausal patients with hormone receptor-positive metastatic breast cancer remains a challenge. This decision was further complicated by a phase III trial conducted by SWOG that demonstrated an improvement in survival for the combination of anastrozole and fulvestrant. In this trial, anastrozole was administered at 1 mg daily alone or in combination with fulvestrant at 500 mg on day 1 and 250 mg thereafter.
Based on these results, Joyce A. O'Shaughnessy, MD, questions the efficacy of the 1 mg dose of anastrozole as a first-line treatment in this setting. Moreover, several questions remain unanswered regarding the optimal first-line treatment for these patients. Adding to the quandary, Sara Hurvitz, MD, points out that patients who received prior tamoxifen did not benefit as substantially from the combination.
Edith A. Perez, MD, believes the combination should not be a first-line choice. Instead, she believes the standard of care should be the 500 mg dose of fulvestrant alone. Andrew D. Seidman, MD, adds that men with ER-positive, tamoxifen refractory metastatic breast cancer also respond well to treatment with fulvestrant, further indicating that it should be a preferred first-line treatment. However, Hope S. Rugo, MD, suggests that many physicians administer aromatase inhibitors (AIs), such as anastrozole, in the first-line setting, since AIs are administered orally.
Based on the SWOG and other trials, O'Shaughnessy now preferentially administers the 500 mg dose of fulvestrant in the first-line setting for tamoxifen-naive patients. However, she notes, there are still questions about whether the SWOG results apply to other AIs, such as letrozole, which is being examined in combination with the novel CDK 4/6 inhibitor palbociclib. In general, Rugo notes, she would rather enroll patients to the clinical trial exploring palbociclib with letrozole, rather than selecting whether to use fulvestrant, anastrozole, or the combination.
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Sara Hurvitz, MDAssistant Professor & Director,
Hematology/Oncology Breast Cancer Program, UCLA's Jonsson Comprehensive Cancer Center, Los Angeles, California
Joyce A. O’Shaughnessy, MDCo-Director, Breast Cancer Research
Baylor Charles A. Sammons Cancer Center
Texas Oncology, PA/US Oncology,
Edith A. Perez, MDDeputy Director of the Mayo Clinic Cancer Center, Director of the Breast Cancer Translational Genomics Program and the Breast Program at Mayo Clinic,
Hope S. Rugo, MDProfessor 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, MDProfessor of Medicine, Weill Cornell Cancer Center, Attending Physician at Memorial Sloan Kettering Cancer Center,
New York, New York
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