Cases from the Community: Investigators Provide Their Perspectives on the Practice Implications of Emerging Clinical Research — A Special Video SupplementCase discussion: A 78-year-old woman with de novo ER/PR-positive, HER2-positive mBC
3:30 minutes.
TRANSCRIPTION:
DR LOVE: So we put together this scenario actually to address the question of the PERTAIN study that was presented at the San Antonio meeting. Let me describe the case, and then you can talk about that. So the case is a 78-year-old woman who presents with de novo HER2-positive breast cancer and metastatic disease. And we said that the patient had asymptomatic, biopsy-proven lung mets. And so the question here is, you have an older patient. Obviously, maybe you’d like to be able to get away with not using chemotherapy. Traditionally, or standard approach in general, I think, might be the CLEOPATRA-type approach for chemotherapy as given with trastuzumab and pertuzumab. But the question is whether or not people would consider using endocrine therapy and anti-HER therapy, either trastuzumab or trastuzumab and pertuzumab. And actually about half of the audience and a number of the faculty people would use that strategy, mainly with pertuzumab and trastuzumab. What are your thoughts about this? And can you talk a little bit about what the PERTAIN study looked at? DR SMITH: I would not be keen to use that, because traditionally — of course there were 2 trials in metastatic breast cancer with endocrine therapy and trastuzumab alone. Both of them showed a minor benefit, a minor improvement with the addition of trastuzumab, but the results were still poor. And just adding in pertuzumab I don’t think is going to — I wouldn’t anticipate would change that much, whereas the CLEOPATRA trial with chemotherapy with docetaxel along with trastuzumab and pertuzumab had really dramatically good results. And we and other centers are seeing long-term remissions and, I suspect, possibly some cures. So the challenge is, what kind of chemotherapy are you going to use here? I’d be very reluctant to use docetaxel in the dose used in the CLEOPATRA trial because of the age and frailty of the patient. I would be inclined, again, to use either weekly paclitaxel, which is well tolerated, or one of the other options that came up, that I’ve used myself, is vinorelbine. And there are good data on vinorelbine with anti-HER2 therapy. It’s kind of not such a — what’s the word? — it’s not such a jazzy front-line drug, really, but it’s very well tolerated. I actually treated — my record is a 93-year-old lady, with vinorelbine and trastuzumab, not with pertuzumab. And it was very well tolerated. So that’s what I would be doing. And I’d be doing it because I would anticipate that we might get good long-term remission. And the other thing is, you won’t need to use too much chemotherapy. It’s almost like a starter. And you’d aim at 6 courses, but if she got a very rapid early remission, which sometimes these patients do get, you might consider just maybe stopping the chemo after 4 courses or so and going on with the anti-HER2 therapy alone. |