60 yo, 2.1-cm node-neg IDC, ER+/HER2-neg adj TC + AI: Systemic Tx if chest wall recurrence 2 y later and NED?


60 yo, 2.1-cm node-neg IDC, ER+/HER2-neg adj TC + AI: Systemic Tx if chest wall recurrence 2 y later and NED?

60 yo woman, s/p mastectomy for a 2.1-cm IDC, negative nodes. Patient receives TC followed by anastrozole, but 2 years after starting anastrozole a small lesion is removed from the chest wall that proves to be a recurrence. No other disease is detected clinically or on imaging. Both the primary tumor and the recurrence are ER-positive/HER2-negative. What systemic treatment would you recommend?

Kimberly L Blackwell, MD
Professor of Medicine
Director, Breast Cancer Program
Duke Cancer Institute
Durham, North Carolina
Answer: AC/paclitaxel Exemestane + everolimus

Data from the CALOR study demonstrated a benefit with adjuvant chemotherapy for patients who experienced a local or regional recurrence. Hence my recommendation would be 4 cycles of AC/paclitaxel. I would follow that with exemestane and everolimus.

Lisa A Carey, MD
Richardson and Marilyn Jacobs Preyer
Distinguished Professor for
Breast Cancer Research
Chief, Division of Hematology
and Oncology
Physician-in-Chief
North Carolina Cancer Hospital
Associate Director for
Clinical Research
Lineberger Comprehensive
Cancer Center
Chapel Hill, North Carolina
Answer: AC or CMF

This is a difficult decision. The CALOR trial that studied the effect of adjuvant chemotherapy for patients with local/regional recurrence showed a bigger benefit for the ER-negative group of patients than the patients with ER-positive disease. A longer follow-up is needed to determine the effect on the ER-positive subgroup. I would have a conversation with the patient who developed a recurrence in the chest wall about additional therapy and would lean toward treatment with AC or CMF.

Julie R Gralow, MD
Professor, Medical Oncology
Jill Bennett Endowed Professorship in Breast Cancer
University of Washington
School of Medicine
Director, Breast Medical Oncology
University of Washington School of
Medicine/Seattle Cancer Care Alliance
Member, Clinical Research Division
Fred Hutchinson Cancer
Research Center
Seattle, Washington
Answer: Switch to tam and possibly cape

I would change endocrine therapy because the patient has experienced relapse on anastrozole after only 2 years. I would favor tamoxifen, so she will not have to receive monthly shots with fulvestrant. The CALOR trial demonstrated a benefit with adjuvant chemotherapy for patients with a local or regional recurrence of breast cancer. The benefit in the ER-positive setting was not as impressive as the benefit for the ER-negative subgroup. But chemotherapy with capecitabine would be a consideration.

Clifford Hudis, MD
Chief, Breast Cancer Medicine Service
Solid Tumor Division
Department of Medicine
Memorial Sloan-Kettering
Cancer Center
Professor of Medicine
Weill Cornell Medical College
New York, New York
Answer: Change ET, add CMF or doxorubicin-based chemo

The recurrence has occurred after a relatively short period of time, and the tumor is likely to be refractory to conventional therapy. I would recommend another course of adjuvant chemotherapy. Because the patient had previously received TC, I would opt for CMF or doxorubicin-based treatment. I would also change her hormone therapy.

Ian E Krop, MD, PhD
Associate Physician
Dana-Farber Cancer Institute
Assistant Professor of Medicine
Harvard Medical School
Boston, Massachusetts
Answer: AC tam

Based on the CALOR data,I would offer this 60-year-old patient who developed a chest wall recurrence 2 years after adjuvant treatment doxorubicin/cyclophosphamide followed by tamoxifen.

Kathy D Miller, MD
Co-Director, IU Simon Cancer Center Breast Cancer Team
Ballvé Lantero Scholar in Oncology
Associate Professor of Medicine
Department of Personalized Medicine
Division of Hematology/Oncology
The Indiana University Melvin and Bren Simon Cancer Center
Indianapolis, Indiana
Answer: Change ET

I would change the endocrine therapy for a patient who developed a recurrence in the chest wall.

Joyce O’Shaughnessy, MD
Co-Director
Breast Cancer Research Program
Baylor-Charles A Sammons
Cancer Center
Texas Oncology
US Oncology
Dallas, Texas
Answer: Nab paclitaxel/cape fulvestrant

My recommendation for a 60-year-old patient who experienced a recurrence in the chest wall 2 years after starting anastrozole would depend on the tumor biology. I would consider how highly proliferative and how strongly ER/PR-positive the tumor was. If it was a highly proliferative ER-positive tumor, I would offer the patient nab paclitaxel/capecitabine for 6 months, followed by fulvestrant.

Hope S Rugo, MD
Professor of Medicine
Director
Breast Oncology and
Clinical Trials Education
University of California, San Francisco
Helen Diller Family Comprehensive
Cancer Center
San Francisco, California
Answer: Change ET

I would change the endocrine therapy a patient was receiving if she developed a recurrence in the chest wall 2 years after starting anastrozole.