Cases from the Community: Investigators Provide Their Perspectives on the Practice Implications of Emerging Clinical Research — A Special Video SupplementUse of capecitabine for aromatase inhibitor-refractory mBC
5:02 minutes.
TRANSCRIPTION:
DR LOVE: So here’s another case, difficult situation: Fifty-nine-year-old postmenopausal woman presents with a 6-cm inflammatory, clinically node-negative breast cancer. This is in 2014. ER-positive, HER2-negative, gets neoadjuvant dose-dense AC/paclitaxel followed by surgery with residual disease, but nodes negative. Gets adjuvant anastrozole for a year, and the tumor markers start to rise. And she develops bone mets, as documented on bone scan, with a positive biopsy. Other scans are negative — bone-only disease. She gets letrozole and denosumab but has disease progression after 3 months. She gets fulvestrant and palbo but has neutropenia that’s problematic and delays treatment. She has to be transfused for pancytopenia. And on bone marrow biopsy now has involvement in her marrow. So the doc is planning or thinking about starting low-dose capecitabine in this situation, trying to, quote, rescue the marrow, but really wants to know about that thought, about low-dose capecitabine. And again, what about everolimus? DR O’SHAUGHNESSY: So this is not an uncommon scenario, particularly in your lobular cancers or some of your luminal A ductals, but particularly lobular. I’ve got a patient right now, came in again, one of these — it was a neglected locally advanced. And she had diffuse bony — lobular, though. It’s not painful. It’s just in the marrow. And she’s actually getting letrozole and palbociclib. And she’s transfusion dependent still. It’s very common. It takes about 4 months to clear out enough cancer out of that marrow and just for the lifespan, the red blood cells to be born and to survive. I tell patients all the time, “You’ll probably be transfusion dependent for about 4 months. But as we get out further they’ll be spread out more, and then there’ll be enough cytoreduction in that marrow that you won’t need it anymore.” Now, with the neutropenia, of course, what I would try to do is reduce the dose of the palbociclib down to 100 and even down to 75, staying with the 21 days on, 7 days off. So I would try to stick with palbo as much as I could, because the patient’s marrow is just going to be more sensitive to whatever it is you give her outside of just an endocrine therapy alone. Now, endocrine therapy alone in this particular patient, no. This particular patient is in a different situation, because she’s already had AIs. And so her disease is progressing through AIs. But in general, AI therapy alone can be very helpful to these patients, but you just have to be patient. It takes about 4 months. Even with chemotherapy, it takes 4 months. It doesn’t make any difference what you use. But capecitabine is certainly a very reasonable option for this patient. But I wouldn’t use low dose. I think we’ve got to be very careful with capecitabine. It’s a very, very important agent for patients. And it’s not so much dose dependent. It’s more schedule dependent. So reducing the dose really can help reduce toxicities like hand-foot syndrome, diarrhea, but it won’t necessarily reduce your marrow toxicity, for example, because it’s a schedule dependency. But the thing is, is that if you don’t give enough of it, you’re going to compromise efficacy. I see that all the time. And I am not a big fan of the 7 on, 7 off, because we don’t have randomized data. And in my experience in terms of the longevity, the durability of these responses — it’s anecdotal, but that’s been my experience. I’ve used a lot of capecitabine. So I think it’s really important to stay with the 14/7 and to get as many pills in as possible. But you’ve got to expect myelosuppression in this situation. I don’t worry at all about anemia. You just take care of the anemia with transfusions for about 4 months. If somebody’s bottoming out their neutrophils, though, all the time, that’s a different matter. Generally speaking, that doesn’t happen that badly, Neil, with capecitabine in this situation. It does with paclitaxel, for example, even, like, weekly paclitaxel, where we don’t see myelosuppression. You do see it in this situation. These marrows are definitely more sensitive, more vulnerable. But you can get away with capecitabine. But I think it’s really important to give as much capecitabine as the patient can tolerate in terms of hand-foot, diarrhea, et cetera. |