Case Studies: Treating Metastatic Breast Cancer

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Harold Burstein, MD, shares a clinical experience regarding an older woman with estrogen-receptor (ER)-positive breast cancer who presented with pulmonary nodules and metastatic cancer in her lung. His practice initiated paclitaxel chemotherapy in this patient, who responded poorly, experienced many side effects, and required hospitalization for pneumonitis. Burstein and his colleagues discontinued chemotherapy and subsequently began treating her with an aromatase inhibitor. This patient had a fairly immediate positive response, and continues to do well after 8 months. While the sense of urgency leads many oncologists to opt for chemotherapy in patients with more advanced disease, says Burstein, it is important to consider endocrine therapy. In some cases, patients will have a better response.

Adam Brufsky, MD, shares his experience regarding chemotherapy use in breast cancer patients. One woman with ER-positive breast cancer had received adjuvant therapy with doxorubicin and cyclophosphamide followed by paclitaxel 5 years before Brufsky treated her. She relapsed with disease in her liver and subsequently received many standard therapies, such as weekly paclitaxel, weekly vinorelbine, and weekly gemcitabine.

Following the FDA approval of eribulin, Brufsky decided to try the drug as fourth-line therapy. In 2 to 3 months, her liver started to recede, and she was effectively maintained on eribulin for a year. Brufsky comments that eribulin is fairly well tolerated, although it is associated with myelosuppression, neutropenia, and neuropathy. In patients who experience side effects, particularly neutropenia, Brufsky often reduces the dose. In triple-negative disease, Brufsky considers eribulin as his preferred second-line agent.

Brufsky highlights the importance of third- and fourth-line treatments, particularly in the management of human epidermal growth factor receptor (HER2)-positive breast cancer. He mentions that many pharmaceutical manufacturers pursue first-line indications for breast cancer. In his opinion, the real challenge for oncologists occurs when patients relapse. Effective first-line options, such as trastuzumab, have demonstrated 18-month progression-free survival outcomes, explains Brufsky.

Second-line therapies, such as ado-trastuzumab emtansine, or TDM1, for HER2-positive disease and exemestane and everolimus for ER-positive disease, have demonstrated progression-free survival of a year or more. The most significant struggle in treatment involves asymptomatic individuals with progressive metastatic disease after failing first- and second-line regimens. These patients will quickly deteriorate if not appropriately treated. Brufsky says that one advantage of using eribulin is that it has demonstrated improved survival in the third- and fourth-line setting. He comments that additional emphasis should be placed on researching treatments for asymptomatic patients who have relapsed after multiple treatments.