Breast Cancer Update, Issue 2, 2016 (Video Program) - Video 14A 49-year-old woman with recurrent HR-negative, HER2-positive mBC
5:24 minutes.
TRANSCRIPTION:
DR LOVE: So let’s talk about your next patient, the 49-year-old lady. DR GOETZ: Okay. So this is actually a patient that was referred to us. She originally was diagnosed with a high-grade DCIS. Interestingly, at the time of resection there was some areas of microinvasion. The patient ultimately underwent a mastectomy because of close margins. And interestingly, the pathology at the time of surgery did show evidence that the microinvasive disease was ER-negative and HER2-positive. She was treated locally with tamoxifen, interestingly, as a, quote, adjuvant therapy for prevention of recurrence in her contralateral breast cancer. And within about 2 to 3 years, she ultimately presented with a large right-sided chest mass. And workup at that time demonstrated she had evidence for multiple enlarged lymph nodes on the right side, this large mass but, interestingly, no visceral involvement. And biopsy at that time demonstrated ER-negative, HER2-positive breast cancer. DR LOVE: Could I just ask, if you had seen her at that point after she had the high-grade DCIS removed, would you have given her tamoxifen? DR GOETZ: I think the data obviously now really support the fact that — Craig Allred’s secondary analysis of the NSABP-B-24 study suggests that there really is no benefit for the use of tamoxifen in ER-negative DCIS. Now, in this situation, she had some areas of microinvasion, but that microinvasion actually was also ER-negative. So the answer, Neil: I would not support the use of tamoxifen in this situation. DR LOVE: So what was the next step with this lady? DR GOETZ: After she was worked up, as I mentioned, she did have evidence for this mediastinal mass. Also a number of areas of lymph node involvement as well as bone metastases. And so at that time, we did treat her with a combination of pertuzumab/trastuzumab as well as docetaxel. And she had received a total of 4 cycles of the combination with chemotherapy, and after 4 cycles we transitioned her to just maintenance pertuzumab and trastuzumab. She had a very nice response. In fact, she had a complete response to therapy and did well ultimately, until about 2 years later when she again had evidence for recurrence, this time really in the same area in the right chest wall. And we again rebiopsied that just for confirmation. That again was ER-negative, HER2-positive. DR LOVE: So what was your thinking at that point? She’s kind of in a pretty typical second-line situation now. DR GOETZ: Yes. So I think at that time, we obviously were aware of the emerging data with T-DM1 and the fact that this was a well-tolerated drug that could provide durable responses and potentially, obviously, as you know, better tolerated than lapatinib and capecitabine. And so that’s what we did. We treated her with T-DM1. And really she’s been maintained on T-DM1 since February of 2014. And at this time — we just saw her just a few weeks ago, and she continues to do very well with no evidence of disease recurrence. DR LOVE: Any tolerability issues with the T-DM1? Any hair loss, any nausea, any thrombocytopenia, LFTs? DR GOETZ: Yes. So she did not have any evidence for nausea or thrombocytopenia. We’ve seen some slight increase in her liver enzymes. And she has actually required a dose reduction twice on the T-DM1 because of the liver enzyme issue. But in each situation she’s done well. Her liver enzymes have improved after the dose reduction. DR LOVE: Any thoughts about where things might head if she were to develop another progression on T-DM1? DR GOETZ: Sure. I think this is where things are relatively wide open in the field of HER2-positive breast cancer, because once T-DM1 has firmly come in as second-line therapy after the pertuzumab-based regimen, we don’t really have, if you will, a clear winner or a choice that I think that we all think about. So this is an area where I typically will focus or try to identify clinical trials for patients who have progression. Obviously if a patient had ER-positive, HER2-positive breast cancer, one could think about continuing or going back to anti-HER2-based therapy in combination with hormonal agents. But I think in this particular patient, we would be using drugs with probably not a whole lot of data. For example, the question of lapatinib and trastuzumab in this situation would be something that I would normally think about in the past, but again, without not a lot of data in this situation. |