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] BOUT
L E T ’ S TA L K A
M E TA S TAT I C B R E A S T C A N C E R :
Answers to Your Most Pressing
Medical
and
Psychosocial Concerns
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Mission
Young Survival Coalition
(YSC) is the premier
international organization
dedicated to the critical
issues unique to young
women and breast cancer.
YSC
works
with
survivors, caregivers, and
the medical, research,
advocacy and legislative communities to increase the quality
and quantity of life for women diagnosed with breast cancer
ages 40 and under.
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Tonight’s Speakers
Generosa Grana, MD
Professor of Medicine, CMSRU
Director, Cooper Cancer Institute
&
11-Year Stage IV Survivor
Dikla Benzeevi
Metastatic Breast Cancer
• Presentation
– Sites of Disease
– Prognosis
• Treatment Options
– Hormonal Therapy
– Chemotherapy
– Biologic Therapy
– Radiation
• Supportive Measures
– Bisphosphonates, etc.
Important Elements
• Defining goals
• Communicating with oncology team & with
family
• Early use of palliative care / supportive
care resources
• Use of psychosocial support services
Metastatic Disease Prognosis
Determining Factors:
• Sites of recurrence
– Skin, nodes>pleura, bone >lung, liver
– Brain > meninges
• Time from diagnosis to recurrence
• Type of tumor (ER, HER2/neu)
• Significant improvements with available
new drugs (chemo, hormonals, biologics)
Current selection of therapy
• Based on sites of disease – urgency
• Previous therapy (prior anthracyclines, taxanes,
type of hormonal therapy)
• Pre-existing toxicity (neuropathy,
cardiomyopathy, other)
• Menopausal status
• ER / PR status
• HER2/neu status
• Patient goals (weekly vs. Q 3 week, oral vs. IV,
hair loss vs. not, etc) (compliance)
Goals of Treatment
• Palliation of symptoms
• Improve survival
• Tumor response
Systemic Treatment Options
Metastatic Disease
ER &/Or PR +
Non-life threatening
Disease
-Hormone Therapy
ER- / PRHer 2 neu –
-Chemotherapy
Single Agent
Combination
Her 2 – neu +
Er- / Pr-Her2 targeted
+ Chemo
Er &/or Pr +
-Hormone Rx
Hormone +
Herceptin alone
Management of
Metastatic Breast Cancer
Diagnosis of metastatic breast cancer
Determination of sites and extent of disease
Assessment of HER2, HR status, disease-free interval, age, and menopausal status
No life-threatening disease,
hormone responsive
Hormone unresponsive or
life-threatening disease
First-line hormonal therapy
Response
First-line chemotherapy
No response
Second-line chemotherapy
Progression
Second-line hormonal therapy
Progression
No response
Progression
Response
Third-line chemotherapy
Progression
Supportive care
Third-line hormonal therapy
No response
Debates
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•
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•
•
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•
Chemotherapy vs. Hormone Therapy
Single Agent vs. Combination Therapy
Sequence of agents
When to integrate hormonal agents if ER+
Sequence in HER2/neu + disease
Approach to triple negative disease
Approach to BRCA1/2 + disease
What Are The Options Following
Tamoxifen?
Tamoxifen
First treatment
Second treatment
Third treatment
Fourth treatment
Nonsteroidal AI
Fulvestrant
Steroidal AI
Fulvestrant
Steroidal AI Nonsteroidal AI
Nonsteroidal AI
Steroidal AI
Other options for subsequent therapy: progesterone agents, high-dose
estrogen, AI + everolimus, clinical trial
Hormonal Therapy Options for
Metastatic Disease
Premenopausal
Postmenopausal
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•
•
Antiestrogens (SERMS)
– Tamoxifen
– Toremifene
Ovarian Suppression
Antiestrogens + os
Antiestrogens (SERMS)
Aromatase Inhibitors
SERDS (Faslodex)
Progestins
Androgens
Estrogen
Recent Additions
• Chemotherapy:
– Halaven (erebulin)
– Others in testing
• HER2/neu based therapy:
– Pertuzumab
– Kadcyla
– Neratinib – in testing
• Hormonal therapy:
– Faslodex
– Exemestane + Afinitor
• Novel compounds
– Parp inhibitors
– Vaccines
– Others
Future Choices
• Genetic profile of tumor
– Caris, individual institutional research
programs
• Genetic profile of host – metabolizing
pathways???
• Better understanding of pathways and
relationship between pathways
GOOD NEWS!
Breast Cancer Therapeutics: 2013
Paclitaxel
Docetaxel
Dolastatin
Ixabepilone
Benzoylphenylurea
Angiogenesis:
Sexaminib
SU6668
Cilengitide
Bevacizumab
HuMV833
Erlotinib
WNT
Cilengitide
SU6668
Cells
Vitaxin 2
Sexaminib
CAI
Gefitinib
Endostatin
Trastuzumab ECM
Angiostatin
Lapatinib
Thalidomide
Growth Factors
Neovastat
(eg, TGFa)
2-Methoxy Estradiol
Tipifarnib
Sorafenib
BMS-214662
Sunitinib
Hormones
(eg,
Bombesin)
Vandetanib
(eg,
Estrogen)
Motesanib diphosphate
Matrix Metalloproteinases:Survival Factors
(eg, IGF1)
Batimastat BB-94
Marimastat BB-2516
BMS-275291
Bryostatin-1
BAY 12-9566
Everolimus
COL3
Temsirolimus
Oxaliplatin
Gemcitabine
Irofulven
5-Azacytidine
Decitabine
Fazarabine
Depsipeptide
Flavopiridol
17AAG
Bortezomib
CC49
LMB-9
Mab CO17-1A
Ad-p53
Oblimersen
IL-4
IL-12
IFN
Cytokines
(eg, ILs, IFNs)
UCN-01
Bortezomib
Death Factors
(eg, FasL)
A Few Interesting Ongoing Studies
• Hormone +:
– Sorafanib + Letrozole
• Triple negative
– Various agents + Avastin
– High GPMB expressing – CDX-011 (celldex)
– Parp inhibitors
• Others:
– Abraxane + Afinitor
Importance of Bone Targeted Therapy
• Bisphosphonates
– Zoledronic Acid IV
– Pamidronate IV
• Rank Ligand inhibitor- Denosumab sq
Role of Radiation
• Focused treatment for symptom palliation
• Quadramet IV for more general pain
control
What Does It Mean In My
Everyday Life?
• Common physical effects and things to
watch
• Common psychosocial concerns
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Sharing Our Stories
Dikla Benzeevi
11-year Stage IV Breast Cancer
Survivor and Advocate
Question and Answer Session
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A Free Resource Just For You
Metastatic Navigator
Comprehensive, easy-to read 90+ page print
resource and forms reviewed by medical experts
To order, visit youngsurvival.org or call
646.257.3000
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