Combination of Anastrozole and Fulvestrant in MBC

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: Monday, June 10, 2013
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Selecting 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.
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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