What are your choices of therapy?
So the good news about this case is that there are a number of therapies. If you assume the patient is relatively asymptomatic, her bone pain has gotten worse but she's still managing her pain with maybe an occasional narcotic at night to sleep, but other than that is doing pretty well, then in my practice I would want to avoid chemotherapy at most costs. Even with multiple liver lesions, patients liver function can still be good. Remember, this is a woman who just 3 years ago got our best chemotherapy, adriamycin cytoxin and paclitaxel. So I'm not really inclined to jump back on the chemotherapy bandwagon at this point.
What has she not had in the endocrine domain? She's not had tamoxifen, she's not had a type 1 aromatase inhibitor which is exemestane, and that's it. What you want to do is think about incorporating anti-estrogen therapy. It always makes me feel a little better if you can layer a targeted agent on top of that.
In this patient my choice would be exemestane everolimus based on the BOLERO2 data. I was quite impressed, at least in the New England Journal of Medicine publication, the independent review showed a 6 month improvement in progression-free survival. The way I would describe my recommendations to the patient is "I really don't want to start you on the chemotherapy pathway at this point, and we have anti-estrogen therapies that you've not had, both pills being exemestane or tamoxifen, and we have a targeted agent known as everolimus that shown to make both of those drugs work better."
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