Cases from the Community: Investigators Provide Their Perspectives on the Practice Implications of Emerging Clinical Research — A Special Video SupplementTherapeutic options for patients with ER-positive BC and disease progression on palbociclib-based therapy
2:38 minutes.
TRANSCRIPTION:
DR LOVE: So we got a bunch of cases of people with ER-positive, HER2-negative metastatic disease with progression on palbo, always a challenging situation. Here’s one: A patient in her fifties presents with ER-positive disease with bony and nodal mets, responds to letrozole/palbo for 8 months, then has disease progression, switched to fulvestrant and the palbo is continued at, quote, the patient’s insistence. But she has disease progression after a couple of months. So the question here is, should chemotherapy be given to a patient like this? She has lower-volume disease. Exemestane/everolimus? DR O'SHAUGHNESSY: Yes. We don’t have any data to guide us, Neil, so it’s really just our clinical experience so far. And I have had numerous responses with everolimus and exemestane in this exact situation, in these patients with lower tumor volume, bone, soft tissue, even lung. I have not in the liver. I have not had success, but, I mean, this is strictly anecdotal at this point. We’re going to obviously need data. But what I do if I feel like a woman’s breast cancer is still likely to have endocrine therapy sensitivity, basically phenotypically — it’s not explosive disease. It’s not rapidly, rapidly growing and progressing to other organs. And it’s in the nonvisceral — even lung. I think lung disease is different than liver disease. I think it’s more ER driven — I’ll definitely go on to exemestane and everolimus, based on my clinical experience so far. If a woman has substantial liver metastases, however, I will go on to chemotherapy at that time. Capecitabine is a common choice. If it’s more heavy tumor burden, it’ll have to be a combination. So that’s what I’ve been doing and that’s what I’ve worked out so far in my practice, Neil. I don’t think the fulvestrant after the up-front palbo/AI is certainly very reasonable. We don’t know. Again, there may be a group of patients that benefit. I think, though, continuing the palbociclib, I think — I understand the patient was very insistent on it. But I think in general, I think we would not do that, because I’m not aware of any data, even preclinical data — and it has been looked at — suggesting that that continues to be of benefit. It appears the mechanisms of resistance really don’t have to do with CDK4/6 anymore. So it doesn’t appear to be beneficial to do that. |