Kimberly Blackwell, MD: Choices of Therapy in Breast Cancer

What are your choices of therapy?

This is a patient who lived her life with stage IV breast cancer for a little over 2 years. She's starting to become symptomatic in that her bone pain is more persistent, and you're worried because the lesions that you know can really impact her quality of life are these lung lesions that are now quite sizable — they're obvious on CT scan and some of them are measuring close to 4 or 5 cm. So you're a little bit more worried, she's a little more symptomatic, and the decision making point at this point is do you try to milk out a little more benefit from an anti-estrogen agent or do you switch to chemotherapy? At least in my practice I would start with something kind and gentle like capecitabine as a single agent.

It's also an ideal time when you're making those decisions, which is a big difference from a pill or a shot to oral chemotherapy agent, which is worlds apart in my mind, to sit down and carefully discuss this with the patient. It's also a good time to think about clinical trials and at least in my practice I would be thinking about a repeat biopsy, in part to repeat the ER-status. We know that ER loss can lead to anti-estrogen therapy resistance, and also to think about the genomic predictor models that can help us look for estrogen-receptor mutations and PI-3 kinase mutations. This is kind of a real meaningful point for this patient because you're making a decision to start going down the chemotherapy pathway or the anti-estrogen pathway.

ER+/HER2-Breast Cancer: Case 2

Mary is a 62-year-old woman, who in mid-2014 complained of rib pain. Rib plain films revealed a lytic lesion of the left 5th rib. Bone scan revealed multiple areas of uptake in the lumbosacral spine and ribs.

PET-CT revealed lytic lesions in the lumbosacral spine and ribs, and a 3 cm right upper lobe lesion in the lung with a PET SUV value of 6, indicating malignancy

A mammogram and ultrasound of the left breast revealed a 2 cm speculated mass in the upper outer quadrant of the left breast

Core needle biopsy of this lesion revealed infiltrating ductal carcinoma, ER 80%, Her2 negative

She was placed on denosumab 120 mg SQ monthly, and anastrozole 1 mg orally daily. Her pain resolved within 1 month, and on follow-up CT at 4 months her bone lesions appeared sclerotic and her lung lesion had reduced to 2 cm. Her anastrozole and denosumab were continued

In mid-2015 she again complained of worsening low back pain and left hip pain. Repeat PET-CT demonstrated new lytic lesions in the left iliac crest as well as an enlargement of the lung lesion to 4 cm.

She was placed on fulvestrant 500 mg IM monthly and denosumab was continued. Within 2 months her pain improved, and a repeat CT of the chest in late 2015 demonstrated reduction of the lung lesion to 2 cm

In March 2016 she complained of new right scapular pain. A PET-CT revealed new lytic lesions of the left scapula and right ribs, and a new lung nodule in the left upper lobe 1 cm in diameter with an increase in the right upper lobe lesion to 3 cm