Advances in Breast Cancer Treatment: Expert Panel Discussion of Challenging Cases

Ben Leach
Published: Monday, Nov 07, 2011
Joyce A. O'Shaughnessy

Joyce A. O’Shaughnessy, MD

Advances in the detection, diagnosis, and treatment of cancer are developing at an increasingly rapid pace. Although evidence-based medicine has led to significant progress in our knowledge, skills, and approaches to treating patients with breast cancer, the implementation of these improvements into clinical practice requires continued learning.

Staying abreast of the clinical research may be a good way to keep informed on novel agents and new treatments, but journal articles provide a one-dimensional interpretation of the findings and rarely discuss the practicalities of implementing these treatments into daily clinical practice. Scientific meetings, on the other hand, provide opportunity for interaction and an exchange of ideas. It is this kind of clinical debate where practical experiences are shared and where the discussions can ultimately facilitate the practical application of clinical data.

For this reason, Contemporary Oncology is introducing a series of discussions that highlight challenging cases presented at medical education conferences hosted by our affiliate company, Physicians’ Education Resources (PER).

The following cases were discussed at the 10th International Congress on the Future of Breast Cancer, which was held in Coronado, California, from August 4-7, 2011.

The case discussions were moderated by Joyce A. O’Shaughnessy, MD, a medical oncologist with Texas Oncology-Baylor Charles A. Sammons Cancer Center in Dallas. Other panelists included Hope S. Rugo, MD, director of Breast Oncology and Clinical Trials Education at the University of California, San Francisco Helen Diller Family Comprehensive Cancer Center; and Frankie Ann Holmes, MD, medical/hematology oncologist at Texas Oncology in Houston.

Case 1

How should a patient with triple-negative metastatic breast cancer be treated if she received adriamycin and cyclophosphamide with Taxol (ACT) in the adjuvant setting a year ago?

The panel noted that patients like this one are often difficult to treat because patients with triple-negative breast cancer who recur quickly like this are often refractory to ACT (doxorubicin/cyclophosphamide/paclitaxel), which means that they are likely to be refractory to several other chemotherapy agents.

However, the panelists were quick to note that this does not mean that all chemotherapy agents will be ineffective in treating this patient. The panel referred to a study in which gemcitabine/carboplatin with iniparib was used to treat patients with triple-negative breast cancer. Patients who were given gemcitabine/carboplatin had approximately a 30% response rate with about 6 months of progression-free survival and approximately 1 year overall survival.

Based on the experience of the panel, patients with triple-negative breast cancer tend not to benefit from platinum-based regimens. In this particular case, the panelists felt that eribulin would be another reasonable treatment option. However, the data on how patients respond to eribulin is not very robust because many of the patients in the studies have been heavily pretreated by the time they are enrolled in the trials.

Bevacizumab might also be an option for this patient, but the panel noted that this would depend on whether a triple-negative breast cancer patient has an amplification of vascular endothelial growth factor A (VEGF-A), which tends to be overexpressed in many triple-negative cases.

The panel pointed to promising developments on the horizon that might benefit this particular patient. For example, by the end of 2011, the Human Genome Atlas Project is expected to be completed, and it will give oncologists a better understanding of the key mutations and amplicons indicated in breast cancer. In addition, future studies of novel clinical trials might be exactly what this patient and others like her need.

The panel concluded that somebody who is fairly refractory to ACT is highly unlikely to get a very durable benefit from more cytotoxic therapy.

Case 2

A 37-year-old woman has stage III invasive ductal breast cancer. She is estrogen receptor–positive (ER ) and human epidermal growth factor receptor–positive (HER ), but her progesterone receptor status is unknown. She’s had a bilateral mastectomy performed. She has received ACT for chemotherapy and is continuing on trastuzumab. She has not yet started to take tamoxifen because she is hoping to get pregnant. She has declined a luteinizing hormone-releasing hormone (LHRH) agonist due to her concerns about the side effects. She wants a natural pregnancy and wants to time it appropriately and inline with her treatment. She has 3 embryos available, but no surrogate to carry the embryos. She is a BRCA wild- type, she is not a mutation carrier, and she has resumed menstruation.

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