Patient Profile 3: 43-Year-Old Woman With Metastatic Breast Cancer Progressing Through Multiple Lines of Therapy


Expert oncologist Rena Callahan, MD, shares a real-world clinical scenario of a 43-year-old woman with metastatic breast cancer who progressed through multiple lines of therapy.


Shanu Modi, MD: Why don’t we move on to another case then, and Rena I’ll have you present your patient.

Rena Callahan, MD: Great. In just getting back to your point to the previous case, in neratinib there is some interesting preclinical data about in tucatinib resistance cell lines that you might be able to get response with neratinib, we have lots of options even as the order is changing. This case is unusual. I picked it as the exception rather than the rule, this patient is 43 years old. In 2011, she had early-stage disease. She had an oncotype of 24. At that time we had discussed chemotherapy because she fell into that intermediate range but she didn’t want it. She was on tamoxifen or said she was taking tamoxifen and she developed an axillary recurrence about a year and a half later. She did have surgery; she did have radiation at that time. She was offered chemotherapy but declined and then she went back on tamoxifen and stayed on it she said religiously after that. Then at some point she was lost to follow up and about 5 years later I got a phone call, it was around Christmas that she was in the ER [Emergency Room] with leg weakness and she had cord compression just diffuse mets [metastasis] throughout her spine along with mets to the lung, liver, multiple lymph nodes. It was everywhere. Pleural effusion. She had biopsy and this was a pleural biopsy which showed that her disease was now HER2+ [Human Epidermal Growth Factor Receptor 2]. I offered taxane HP at that time, but she declined. There were a variety of reasons which we can go into but she flat out declined. I offered her T-DM1[trastuzumab deruxtecan] and she did great on that for about a year-and-a-half at least. She was doing great and feeling great.

Shanu Modi, MD: So many interesting things about this case as you said. I mean did you suspect that perhaps she wasn’t taking her tamoxifen initially that may have led to that first recurrence in the first place, but she did well afterwards?

Rena Callahan, MD:Yes. Prior to the axillary recurrence, I just don’t think that there was consistency in taking endocrine therapy.

Shanu Modi, MD: And the fact that this was presumably HER2- cancer and is now HER2+, we all see this and it highlights the importance of biopsying disease at the time of recurrence to better cater our therapy, she has whole new group of options to choose for us to use to control her disease. You mentioned it but I am curious why did she decline the taxane and Herceptin and Perjeta? Was there a specific thing that bothered her about that?

Rena Callahan, MD: It was mostly the taxane that bothered her. Chemotherapy, the idea of chemotherapy, she was just – even from the get go and when the oncotype was 24 and we were talking about, when she had axillary recurrence and that might have been a good time to get some chemotherapy. She just couldn’t wrap her head around chemotherapy and especially taxane when going over what are some of the potential adverse effects including hair loss and neuropathy, she didn’t want that. Whereas when discussing T-DM1 at least at the time it was new, we would often discuss antibody drug conjugate when it was a smart bomb. It was sexier at the time and didn’t feel like chemotherapy, towards the uptake it was OK with her.

Shanu Modi, MD: She went on to the T-DM1 and you said she had a good response initially.

Rena Callahan, MD: Yes. She did great but then about a couple years, not quite 2 years later, year and a half later she had progressive disease again in lungs and bones, biopsied again confirmed biomarker status and at that time we talked about again taxane, Herceptin® [trastuzumab] and Perjeta® [pertuzumab]. And again, she was not ready to have that, she did accept the Herceptin® and Perjeta® and she had a few cycles of that before being convinced to add some chemotherapy and Navelbine®[vinorelbine] was acceptable to her. The adverse effects, infusion time, lack of hair loss, she was OK with that. She had that. She did well for a while, for almost a year and then walked into the clinic with bright yellow eyes. At that time, we had to think of other options and finally being able to visibly see her health being affected, although she was the most functional person with jaundice I have ever seen. But she could still see it in the mirror, so at that point she accepted Abraxane® [paclitaxel] and I kept her on Herceptin®. Had a beautiful decline of the bilirubin but then – and she did well for a few months, normalize bilirubin but then it happened again very quickly. Her bilirubin shot up and each of these times we scanned and looked for stentable lesion, unable to find that just diffused throughout the liver and then at that time put her on carbo and Herceptin® and again got a good response in the bilirubin for a few months.

Shanu Modi, MD: She has explosive disease I mean really short benefits with all of these excellent treatments. You walked us through, it sounded like she was involved in the decision making with you in terms of what she was willing and not willing to accept in terms of toxicity and we all have patients like this. Thank goodness we have lots of options for patients to choose from.

Transcript edited for clarity.

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