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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 1 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. 2 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 • • • • • • • 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 • • • • • • • • • 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 20 Sharing Our Stories Dikla Benzeevi 11-year Stage IV Breast Cancer Survivor and Advocate Question and Answer Session 60 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 61 Thank You! Please Complete Post Event Evaluation https://s.zoomerang.com/s/metswebinar 62