Second Opinion

MANAGEMENT OF METASTATIC BREAST CANCERFrom the practice of Abraham B Schwarzberg, MDA 38-year-old premenopausal woman was diagnosed with a 2-cm, Grade III, ER/PRpositive,HER2-positive IDC. CT scan revealed a 1.8-cm nodule in the left lobe of theliver, and biopsy confirmed metastatic disease. The remainder of this patient’s workupwas negative.Select Excerpts from the DiscussionTrack 37DR LOVE: Kathy, what’s your approach to treating patients presentingwith asymptomatic metastatic breast cancer?DR MILLER: I have several patients in my practice who presented withmetastatic disease at the time of initial diagnosis. In the long-term follow-upseries from MD Anderson, a small group of patients were potentially cured,or were at least long-term survivors, of their metastatic disease. These womenwere predominantly treated with anthracycline-based chemotherapy, along withhormonal therapy if appropriate. We do not know how to identify these women,but they did not have multiple, bulky sites of symptomatic disease or less than acomplete response to systemic therapy.I tell patients that in general, metastatic disease is not curable but that Ihave seen exceptions. Among younger women with limited, asymptomaticmetastatic breast cancer, it is reasonable to assume that a few will be long-termsurvivors. A key component is to achieve a complete response to the initialsystemic therapy, so I would begin with an aggressive treatment plan. Theremainder of our decisions will follow from how well she responds to the initialtherapy.For this patient with HER2-positive disease, I would consider the TCHregimen. She also would be eligible for the ECOG-E1105 study, whichrandomly assigns patients to paclitaxel/trastuzumab and optional carboplatinwith or without bevacizumab. I have a patient enrolled on E1105 who is similarto this 38-year-old woman. If she demonstrates a complete response to chemotherapy,we will proceed to local therapy for her primary tumor and continuedtherapy with trastuzumab and hormonal therapy.If she doesn’t experience a complete response, then the best data suggestthat she doesn’t have the possibility of long-term survival and we need to shiftour goals to preserving the quality of her life while still trying to extend thequantity of her life. So we would perhaps make different decisions about localtherapy, about the use of more aggressive hormone therapy and about how longwe might continue the trastuzumab.3