Triple-Negative Breast Cancer: Selecting Chemotherapy

Reshma L. Mahtani, DO:As you’ll recall, this woman had a tough time in the adjuvant setting with chemotherapy and had a very short period of time where she was off treatment and developed recurrent disease, requiring combination chemotherapy. As you can imagine, she’s probably accumulated a lot of side effects from prior chemotherapy and is probably just tired of IV treatment. In that regard, capecitabine seems like a very good choice in terms of tolerability and in terms of the fact that it’s an oral treatment and a non—alopecia-causing treatment. However, when looking at this choice, which is a frequent one for patients who have metastatic breast cancer and progress, capecitabine tends to be a treatment that’s chosen quite often. But I’ve been particularly moved by the data that compared capecitabine and eribulin in the metastatic setting in patients who had gone through first-, second-, or third-line treatment.

In this study, the Study 301, there was no difference between the 2 options. However, in subgroup analyses, there appeared to be an overall survival benefit for patients who received eribulin over capecitabine. I don’t think that there’s any hard and fast correct answer, per se. I think that every decision is a discussion with the patient. Capecitabine may have been very appropriate. But from an efficacy standpoint, I would have probably tried to convince this patient to take eribulin. I do think that given the data I’ve discussed, I would be more in favor of that approach.

As far as a local treatment, in the setting of metastatic disease we tend to reserve local therapies for patients who are having local problems. In this case it could be hemoptysis or postobstructive pneumonia, something of that sort. In general, we try to approach the treatment in a systemic way. I would have probably offered further systemic therapy as opposed to a local treatment.

Whenever we have a discussion regarding a change in treatment for a patient who has metastatic disease, all of the things that were mentioned—including clinical trial data, side effects of treatment, goals of therapy—come into play in discussions with patients. I find that when we talk about efficacy endpoints with patients, there is a bit of understanding about terms that are more meaningful to them, including overall survival. That’s pretty easy for patients to understand, and I find that discussion about a therapy that will allow them to live longer is pretty easy to understand. But of course, we do take into account patient preference for IV versus oral therapy. Certain patients don’t want to lose their hair, and that’s quite bothersome to them. Obviously, all these things come into play when we make the final decision about therapy.

Transcript edited for clarity.

A 55-year-old Woman With Advanced TNBC

June 2015

• Patient History
  • A postmenopausal 55-year-old African American woman who was first diagnosed with breast cancer 2 years ago after discovering a lump in her right breast
  • SH: active with 2 teenaged children
  • Imaging revealed the likelihood of a multifocal lesion (2.5 cm.) in the right breast and right axillary lymph node involvement
• Pathology findings from ultrasound-guided core needle biopsy:
  • Histologic grade 3 invasive ductal carcinoma
  • Hormone receptor status: ER(-), PR(-)
  • HER2(-) IHC, 0
• BRCA1/2testing, negative
• She underwent mastectomy followed by immediate reconstruction; 2 of 20 nodes positive
  • Surgical staging T2pN1M0
• Following surgery, she received adjuvant doxorubicin/cyclophosphamide followed by paclitaxel (12 weeks); pt. had difficulty completing CT due to significant diarrhea and CINV

October 2017

• Routine follow up at 18 months:
  • Patient reported having worsening cough and abdominal pain
  • Imaging revealed 3 lesions in her right lung (<2 cm) and several liver lesions
  • Biopsy confirmed metastatic TNBC
• She was started on treatment with gemcitabine/carboplatin; she required dose reduction for neutropenia; imaging at 3 months showed stable disease

May 2018

• Seven months after starting gemcitabine/carboplatin, imaging showed progression in a single right lung nodule (now 3.2 cm)
• After discussion of her therapy choices, the patient opted for treatment with capecitabine

August 2018

• Imaging at 3 months showed 4 new liver lesions
• She started treatment with eribulin 1.4 mg/m²IV on days 1 and 8 of each 21-day cycle
  • Two weeks after her first dose, she developed grade 3 neutropenia without fever