Kimberly Blackwell, MD: Considerations for Different Therapies in Breast Cancer

What considerations underlie these choices?

This patient, who has now progressed after a second line of anti-estrogen therapy, the things you have to consider is how symptomatic she is, how worried you are about the re-staging findings, and then the third consideration is always what are her therapeutic options. The good news is that she has a lot of therapeutic optics, which is a little more challenging to take care of her because there's not a right or wrong answer at this point.

My thinking in my own practice is that I tend to use anti-estrogen therapy over and over until I run out of them because she's already demonstrated a response to anti-estrogen therapy. In this third-line setting you kind of want to jazz it up a little bit and add a targeted agent. The considerations at least in 2016, your choices for an anti-estrogen agent with a targeted agent really boil down to one of two — you can employ the type 1 aromatase inhibitor exemestane with everolimus, as we have generated very good data about this combination in BOLERO-II, or you could employ either fulvestrant or a type 2 aromatase inhibitor with a CDK inhibitor.

In this patient, she's already had a type 2 aromatase inhibitor, she's already had fulvestrant, so that would push me a little more to the BOLERO-II regimen of everolimus and exemestane.

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