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DR GRADISHAR: One of the satisfying things is we have a lot of different treatment options. The problem is, they’re not oftentimes long-lasting effects in the patient. With respect to eribulin, ixabepilone and nab paclitaxel, I think those are all reasonable treatment options in patients with metastatic disease. And certainly, ixabepilone and paclitaxel and nab paclitaxel — it’s sort of the 800-pound gorilla in the room. There’s a study sitting out there that we’re not going to talk about because we don’t have the data that compares those treatment arms.

But that said, I mean these are active agents. They work in patients with progressive metastatic disease. With nab paclitaxel, there have been studies looking at three-week schedules, weekly schedules. A couple of reports that were relatively recent looked at the survival with the higher-dose weekly schedules, suggesting that 150 mg/m² three out of four weeks might confer the greater PFS and the greatest survival benefit and a cost to greater neuropathy. And with respect to the neuropathy again, that tends to occur, as do the responses at that dose, relatively early. So if you were electing to use that dose, you might be able to get the response if it were destined to happen and then back off from that dose and still the outcome is very much the same. So dose reduction doesn’t necessarily translate into a worse outcome.

Eribulin as part of the EMBRACE study, showed compared to other treatment options, that it was the winner in terms of overall survival. So I think, again, that’s a good reasonable treatment option, and I personally think that’s probably a bit better tolerated than ixabepilone. And we use them all, and we probably would in such a patient over time, but they do have somewhat different toxicity profiles.

DR LOVE: Ian, how do you approach the selection of these agents?

DR KROP: I think we do it based on quality-of-life issues and very simple logistical issues. If somebody lived close enough that can go for weekly therapies, or do they live far away and really should focus on drugs that have a less frequent schedule of administration or preferably an oral drug. What we all would love to have are predictive markers that say, “For a given tumor you’re more or less likely to respond to a given agent,” but we can’t even do that for targeted therapies like everolimus or bevacizumab, and we’re not anywhere close to doing it with conventional chemotherapy.