In the continuation of a case-based discussion, the panel reviews clinical trials looking at potential treatment strategies for a 59 year-old woman with metastatic breast cancer (MBC). In the case study, the patient was diagnosed with ER and HER2-positive MBC and received adjuvant Adriamycin plus Cytoxan followed by paclitaxel with trastuzumab and 5 years of anastrozole. After 8 years, the patient recurred with pulmonary and liver metastases.

Andrew D. Seidman, MD, comments that the treatment recommended by Sara Hurvitz, MD, in part I was provocative and counterintuitive. In this segment, Hurvitz recommended administering a taxane with pertuzumab and trastuzumab in the frontline followed by HER2-targeted therapies alone with the potential to add an endocrine therapy. More data will be available on this treatment approach from the phase II PERTAIN trial, Seidman notes.

In regard to the chemotherapy utilized, Seidman references the HERNATA trial that compared trastuzumab plus docetaxel or vinorelbine as a frontline treatment for HER2-positive MBC. In this trial, both treatment approaches resulted in similar efficacy with significantly less toxicity in the vinorelbine arm, notes Edith A. Perez, MD.

Building off the HERNATA and CLEOPATRA trial, the phase II VELVET trial is exploring the combination of pertuzumab, trastuzumab, and vinorelbine for the first-line treatment of patients with HER2-positive MBC, Perez notes. In the first cohort of the trial, each treatment will be administered sequentially. In the second cohort, vinorelbine will be followed by simultaneous trastuzumab and pertuzumab. Results from the first cohort are expected to be presented at the 2013 San Antonio Breast Cancer Symposium.

In regard to chemotherapy, remarks Hope S. Rugo, MD, one nice thing about vinorelbine is the lack of alopecia. However, it is important to monitor gastrointestinal toxicities. Another treatment option, if approved in this space, could be treatment with T-DM1, Rugo suggests.