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Breast Cancer Case Studies

Kimberly Blackwell, MD: Expectations of Therapy

Kimberly Blackwell, MD
Published Online:Mar 31, 2016
Angela is a 56-year-old woman, who in 2013 was diagnosed with a 4 cm IDC of the left breast, ER positive at 50%, PR negative, and HER2 negative.

ER+/HER2-Breast Cancer with Adam Brufsky, MD, PhD and Kimberly Blackwell, MD: Case 1

What are the expectations of therapy in this setting?

We know on average that when women have progressed on first-line endocrine therapy, the median progression free survival unforunately remains under 1 year. We really want to think about incorporating a targeted agent with the anti-estrogen therapy, or participation in clinical trials. What I would tell this patient is that if I were to start her on an anti-estrogen agents such as exemestane in combination with everolimus, that at least when it was studied with that combination in the first-line setting, the median progression free survival, and there were different endpoints, was about 10.6 months compared to 4.1 months when the anti-estrogen agent was used alone.

I'd also tell the patient that there are added side effects when you add everolimus, and these include mucositis, anemia, and a very rare form of lung irritation/inflammation known as pneumonitis. With everything we do in cancer, we have to highlight the benefits, which is if we add this pill, it will make your anti-estrogen work better, but also highlight the possible side effects.

To summarize what I would tell the patient, I think we would use both pills, which would be a exemestane everolimus combination. It has this benefit of adding about 6 months longer to how the drugs work. There are these side effects and we would have to monitor them closely, at least in my practice when I start it I see the patients 2 weeks into it and 4 weeks into it, so it makes it very similar to the monitoring requirements we see with other targeted agents. Just because I think when patients go home with a pill, they think "oh I don't need to call the doctor because it's not chemotherapy," but I really try to educate the patients up front so they don't get into trouble with the side effects, and I would tell the patient that I think it's worth doing.

ER+/HER2-Breast Cancer: Case 1

Angela is a 56-year-old woman, who in 2013 was diagnosed with a 4 cm IDC of the left breast, ER positive at 50%, PR negative, and Her2 negative. She was treated with four cycles of neoadjuvant doxorubicin and cyclophosphamide, followed by twelve weeks of paclitaxel.

  • She then had a left MRM with AD, showing a residual 1.5 cm tumor with 3/10 LN positive
  • She received anastrozole, and in early 2015 she complained of low back pain and a bone scan revealed multiple areas of uptake in the lumbosacral spine
  • PET-CT revealed lytic lesions in the lumbosacral spine and pelvis, and a 2 cm low attenuation lesion in the liver with a PET SUV value of 10, indicating malignancy

She was placed on denosumab 120 mg SQ monthly, and fulvestrant 500 mg IM monthly. Her pain resolved within 2 months, and on follow-up CT qt 4 months her bone lesions appeared sclerotic and her liver lesion had reduced to 1 cm. Her fulvestrant and denosumab were continued.

  • In early 2016 she again complained of worsening low back pain and left hip pain
  • Repeat PET-CT demonstrated new lytic lesions in the left iliac crest as well as an enlargement of the liver lesion to 3 cm
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