Joyce O'Shaughnessy, MD: Treatment Goals for Patients With TNBC

What are the treatment goals for patients like Connie with TNBC and multiple metastatic sites?

This patient presented with an aggressive triple negative breast cancer, with a large breast mass at presentation and unfortunately with mediastinal lymph and liver metastases right from the beginning. We know life span is approximately 1 year, maybe a little longer, in that situation.

She received a clinical trial therapy, which is terrific because we always want to think first of clinical trials to make advances against this disease. She received nab-paclitaxel, gemcitabine, and bevacizumab and she did benefit from that, with palliation and control of disease.

When she had disease progression, she went on to another standard regimen that targets the inability of triple negative breast cancer to repair its own DNA, doxorubicin plus cyclophosphamide. We commonly use that in the curative setting, but we used that in the second-line setting, which is reasonable.

Again, she benefits from that. Now she progressed again in her liver and her mediastinum, and she needs third-line therapy. There are several options still for this option, but the one that reaches the level 1 evidence with regard to being the best choice for her is eribulin because of the survival advantage the treatment has documented in metastatic breast cancer.

Another combination, for example, that comes to mind, is ixabepilone plus capecitabine combination, which is an FDA approved regimen for patients whose disease had progressed through doxorubicin, cyclophosphamide, 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