Treating Breast Cancer Metastases to the Lung and Brain?

Treating Breast Cancer Metastases to the Lung and Brain? A 37-year-old woman who underwent treatment for a T3N1M0 breast carcinoma presents 15 momths later with metastases. profAskTheExpert brest,braest,cns,metastisis, chemotherapy,female, carcinoma breast estrogen receptor positive,carcinoma,carcimona, neoplasm malignant brain secondary,caarcinoma,neaplasm,adenocarinoma,carconoma,breasts,adenocarcinona,adenocardinoma,mets,malignant neoplasm,neoplasm malignant breast,breast cancer metastatic,carcioma,central nervous system,carcinomas,breast cancer (ERA+),metastsatic,woman,malignancy,ca,breeast,women,adenocarcinomas,cancer,breat,metastatic, hematology/oncology,neoplasms,breasst,adenocarcinoma,mammary,metastses,metastases,metastates, carcinoma breast metastatic,metastasis,metastatis,carrcinoma Jacques Bonneterre, MD, PhD, Head of the Breast Disease Department, Centre Oscar Lambret, Lille, France, and Professor, Breast Disease, Lille II University, Lille, France. Medscape Medscape Hematology-Oncology 08/07/2002 5 2 <h3>Question</h3> A 37-year-old woman underwent a right mastectomy and axillary clearance for a T3N1M0, grade 2, ER-positive, PR-negative, metaplastic breast carcinoma. She underwent 6 cycles of 5-fluorouracil/doxorubicin/cyclophosphamide (FAC) and radiotherapy to the chest wall and supraclavicular area, and was maintained on tamoxifen 20 mg daily. Fifteen months later, multiple nodules were detected in each lung on chest x-ray, and further work-up revealed multiple brain metastases. What would you recommend at this time? Prof. Mehmet Koc <H3>Response</H3> from , 08/07/2002 This is a case of a 37-year-old woman who, 15 months after treatment of a breast carcinoma, relapsed in the lungs and in the brain. The initial treatment was optimal; she had an early relapse with a poor prognosis (ie, brain metastases) but is not symptomatic. First, we would propose immediate radiation therapy in order to preclude the patient from becoming symptomatic, even if such a treatment will not have an impact on the overall survival. Second, tamoxifen should be stopped. We would suggest chemotherapy rather than hormonal therapy since the relapse occurred while the patient was on tamoxifen, the viscera are poorly hormone-sensitive, and the tumor is very fast-growing. The question remains, however, as to which chemotherapy regimen is best. With regard to high-dose chemotherapy, there are no clinical trials comparing high- vs standard-dose chemotherapy that showed a benefit with the higher dose. If the relapse was observed less than 1 year after the end of adjuvant chemotherapy, it can be concluded that the tumor was anthracycline-resistant and, accordingly, a nonanthracycline regimen should be proposed. For such a case, it has been shown that docetaxel was better than vinblastine/mitomycin, even in terms of overall survival.[1] If, however, the relapse occurs more than 15 months after the end of chemotherapy, several alternatives are possible. Depending on the total initial dose of doxorubicin, a FAC-like regimen may be appropriate. However, if the initial dose was 60 mg/m2, the remaining acceptable dose would be too small for this regimen to be proposed. If the total anthracycline dose was lower, a half-dose (50 mg/m2) epirubicin in 5-fluorouracil/epirubicin/cyclophosphamide (FEC 50) could be proposed. A polychemotherapy approach combining taxanes and anthracyclines could be another alternative. To our knowledge, 4 studies with paclitaxel and 3 studies with docetaxel have been published, at least in abstract form.[2-8] Although the overall as well as the complete response rates were slightly higher with the combinations, the time to progression was similar, and the overall survival was longer only in 1 study in the taxane-containing arm.[3] Conversely, tolerability was poorer when a taxane was added, yielding higher rates of febrile neutropenia in the docetaxel arms. These combination regimens should therefore be proposed only in symptomatic patients in whom a rapid response is important. In this patient, however, given that she is asymptomatic, based on the above, we would favor a regimen of docetaxel monochemotherapy. <ol> <li> Nabholtz JM, Senn HJ, Bezwoda WR, et al. Prospective randomized trial of docetaxel versus mitomycin plus vinblastine in patients with metastatic breast cancer progressing despite previous anthracycline-containing chemotherapy. 304 Study Group. J Clin Oncol. 1999;17:1413-1424. <li> Luck HJ, Thomssen C, Untch M, et al. Multicentric phase III study in first line treatment of advanced metastatic breast cancer (ABC): epirubicin/paclitaxel (ET) vs epirubicin/cyclophosphamide (EC). A study of the AGO Breast Cancer Group [abstract #280]. Proc Am Soc Clin Oncol. 2000;19:73a. <li> Jassem J, Pienkowski T, Pluzanska A, et al. Doxorubicin and paclitaxel versus fluorouracil, doxorubicin, and cyclophosphamide as first-line therapy for women with metastatic breast cancer: final results of a randomized phase III multicenter trial. J Clin Oncol. 2001;19:1707-1715. <li> Carmichael J. UKCCCR trial of epirubicin and cyclophosphamide (EC) vs. epirubicin and Taxol® (ET) in the first line treatment of women with metastatic breast cancer (MBC) [abstract #84]. Proc Am Soc Clin Oncol. 2001;20:22a. <li> Biganzoli L, Cufer T, Bruning P, et al. Doxorubicin and paclitaxel versus doxorubicin and cyclophosphamide as first-line chemotherapy in metastatic breast cancer: The European Organization for Research and Treatment of Cancer 10961 Multicenter Phase III Trial. J Clin Oncol. 2002;20:3114-3121. <li> Nabholtz JM, Falkson G, Campos D, et al. A phase III trial comparing doxorubicin (A) and docetaxel (T) (AT) to doxorubicin and cyclophosphamide (AC) as first line chemotherapy for MBC [abstract #485]. Proc Am Soc Clin Oncol. 1999;18:127a. <li> Bonneterre J, Dieras V, Tubiana-Hulin M, et al. 6 cycles of epirubicin/docetaxel (ET) versus 6 cycles of 5FU epirubicin/cyclophosphamide (FEC) as first line metastatic breast cancer (MBC) treatment [abstract #163]. Proc Am Soc Clin Oncol. 2001;20:42a. <li> Mackey JR, Paterson A, Dirix LY, et al. Final results of the phase III randomized trial comparing docetaxel (T), doxorubicin (A) and cyclophosphamide (C) to FAC as first line chemotherapy (CT) for patients (pts) with metastatic breast cancer (MBC) [abstract #137]. Proc Am Soc Clin Oncol. 2002;21:35a. </ol>