Denise A. Yardley, MD: Chemotherapy Combinations with TNBC

Dr. Yardley says that the benefits of cytotoxic chemotherapy in TNBC neoadjuvant, adjuvant, or metastatic treatment are well established, with numerous studies demonstrating the effectiveness of chemotherapy in these settings. Polychemotherapy in ER-poor early disease was evident in both the younger and older patients from The Early Breast Cancer Trialists’ Collaborative Group overview, demonstrating that a substantial risk reduction in recurrence and death from breast cancer is consistent with the notion that TNBC derives substantial benefit from polychemotherapy. In further support, a retrospective analysis of 3 large Cancer and Leukemia Group B (CALGB) trials concluded that ER-tumors derive substantially greater improvements in outcome from modern intensive and extensive chemotherapy regimens.

In the advanced disease setting, combination chemotherapy offers higher response rates and prolonged time to disease progression compared with single- agent chemotherapy. It is often reserved for those with very symptomatic disease, rapid tempo of progression, or those with high tumor burdens and/or visceral crisis.

CASE 1: Triple-Negative Breast Cancer

Rebecca B. is a 48-year-old premenopausal African American woman from Tampa, Florida who works as a nursing administrator for a home healthcare company.

In December 2009, patient presented to her PCP after detecting a mass in her right upper-outer quadrant on self exam; she was referred for imaging and further evaluation.

Mammography and ultrasound revealed a 2.5-cm mass

Core biopsy revealed moderately differentiated invasive ductal carcinoma that was ER-/PgR-; HER2 staining was negative by immunohistochemistry

Patient was referred for whole-breast MRI and surgical evaluation

Patient underwent a lumpectomy of the right breast with sentinel lymph node evaluation

Sentinel lymph node evaluation was positive; patient underwent axillary lymph node dissection

Malignant cells were detected in 1 sentinel and 2 axillary nodes (total 3 of 14 LN+); tumor classified as Stage 2B (T2N1M0)

Post surgery, patient received TAC chemotherapy with docetaxel (75 mg/m2 IV day 1), doxorubicin (50 mg/m2 IV day 1), and cyclophosphamide (500 mg/ m2 IV day 1, cycled every 21 days for 6 cycles), with pegfilgrastim support

Patient received radiation therapy for 6 weeks, including ipsilateral breast and regional nodes

Patient remained disease-free for approximately 3 years

In January 2013, the patient returned to her PCP complaining of intermittent right-upper quadrant pain, fatigue, and unexplained weight loss.

A subsequent CT scan revealed visceral metastases in the liver and lung; bone scan was negative

Liver biopsy was performed and specimen was sent for ER, PR, and HER2 determinations