DR LOVE: So here’s a case that was actually emailed to us. And when I read this, I’m like, “Wow! I’ve never heard of this.” And I thought, I’m going to tell you. And you’re going to say, “Oh, I’ve seen 5 of these people.” But anyhow, we’ll see.

So 67-year-old man with invasive ductal cancer, ER-positive, HER2-positive in 2013 gets a mastectomy, sentinel node, gets TCH chemotherapy and a year of trastuzumab and then is placed on tamoxifen. It says T1cN1 microinvasive, so that’s, I guess, from the sentinel node. So the patient was put on tamoxifen, did well for a year on tamoxifen and then developed respiratory issues with the tamoxifen. And he stopped the tamoxifen. There’s, quote, respiratory issues go away.

Then the patient’s now been rechallenged 3 times with tamoxifen. Every time, after a few weeks on tamoxifen, the patient develops significant shortness of breath, uses inhalers, respiratory support and now is refusing to take tamoxifen. So first of all, I’m curious if you’ve ever heard about anything like this. The doc wanted to know: What about using an AI in the adjuvant setting? Would you consider it? And if so, would you use a GnRH analog with it?

DR O’SHAUGHNESSY: Hmm. I’ve never seen that, Neil, and I hadn’t heard of it, either. But it sure sounds like the doctor nailed that down, that that was relational there for that patient, which is great, a really good thing to do, since tamoxifen is so proven in male breast cancer.

Yes, I definitely would talk to him about an aromatase inhibitor. I would add an LHRH agonist, because you definitely get rebound, of course, increase in LH and FSH, which drives the testes to produce a lot of androgens, which are then converted into estrogens. And just like in the premenopausal woman, you can’t give enough aromatase inhibitor to stop that amount of androgen from being converted into estrogen. So I would utilize an LHRH agonist for him.

And the issue, again, is, how long does he have to tolerate that for? Does he have to go beyond 5 years? Maybe with just a microscopic lymph node — of course, it is HER2-positive. You worry a little bit about that. But at least if I could get him 5 years, a full 5 years of endocrine therapy, I’d feel pretty good about that. And then I’d have to kind of reassess. It’s hard. If he were finishing up the 5 years — it depends on tolerability. But I don't know, for node-positive, HER2-positive, ER-positive, I’m leaning toward a bit more therapy than less therapy these days. So I’d probably say, “Stay on it for a while longer.”