Joyce O'Shaughnessy, MD: Fourth-Line Considerations

What would be your fourth-line considerations in this patient?

In metastatic triple negative breast cancer, unfortunately just a minority of patients live long enough with their metastatic disease to require fourth-line therapy. We don’t have a lot of data in that regard because the life span is short.

Generally speaking, firstline is a taxane, second-line often times is a platinum-based regimen, third-line will be eribulin, though sometimes eribulin can be given in the second-line as well, and that leaves us essentially with the proven regimen of ixabepilone plus capecitabine. Ixabepilone adds considerably to capecitabine, and that’s an FDA-approved option.

We conducted a phase II trial of ixabepilone plus carboplatin, and that has been submitted for publication. It was an active combination that warrants consideration because of these phase II data that are available, but from a phase III, level 1 standpoint, we have eribulin in the second- or third-line and ixabepilone plus capecitabine as a later option for patients who had received an anthracycline and a taxane.

Triple Negative Breast Cancer: Case 2

Connie C is a 56-year-old television producer for a local news station, her medical history is unremarkable for any chronic conditions.

In September of 2014, after presenting to her PCP with a palpable breast mass and fatigue of several months’ duration she underwent a left mammogram revealing a large breast mass.

• A CT scan of the chest/abdomen/pelvis showed a large primary mass in the left breast, multiple enlarged mediastinal lymph nodes, and several hepatic lesions consistent with metastases
• Breast and liver biopsies showed poorly differentiated, mammary adenocarcinoma that was ER-, PgR- and HER2- (triple-negative) with Ki67 staining 70%
• She began first-line chemotherapy with doxorubicin

In February of 2015, she returns with increasing fatigue and back pain; her CT scan shows progression of the hepatic lesions, and bone scan shows new lesions in the T4 and T5 vertebra. At the time of progression, her ECOG performance status (PS) is 1.

• She began therapy with docetaxel plus capecitabine as part of a clinical trial and her disease stabilized after 5 cycles

In June of 2015, she returns for follow up with worsening back pain and intermittent dyspnea. Her CT scan at the time of progression shows the bone lesions worsening and several new bilateral pulmonary lesions.

• Patient remains active, with good liver and renal function; her ECOG PS remains at 1
• The oncologist initiates therapy with eribulin at a dose of 1.4 mg/m2; she tolerates the therapy well and shows a partial response after 5 cycles, with improvement of the bone and pulmonary lesions, and stable hepatic disease