How is metastatic breast cancer treated effectively at 36?

Question

Hello doctor,

The patient is a 36-year-old female. She is a metastatic breast cancer patient. The diagnosis was made three years ago. Metastasis was found this year through an FDG PET CT scan. The primary treatment was for breast lumpectomy, followed by chemotherapy (3 FEC + 3 Docetaxel), and radiation therapy.

For MBC at the liver, the patient received Trastuzumab plus Leuprolide 3.75 (8 cycles) and Letrozole 2.5 mg. There was a progression to bilateral oophorectomy plus DJ stenting at the urethra. Also, Trastuzumab plus Letrozole. After progression on Trastuzumab and Fulvestrant.

Is the present treatment plan as per the guidelines of ESMO or ASCO?
If not, then what does the guideline say?
The patient feels pain in the abdominal region, which worsens at night. As per the urologist, there is no gynecological or urological problem, as very recently the DJ stent was replaced with a new one. What is the solution?

Kindly guide.

Thank you.

Answer 1

Hello,

Welcome to icliniq.com.

It looks like she is having progressive metastatic breast cancer, triple positive (ER+, HER2+). She received chemotherapy, hormonal therapy, and targeted therapy (Trastuzumab). She also underwent BCS (breast-conserving surgery), oophorectomy, and radiotherapy.

Despite all this treatment, she progressed twice. Before I give some suggestions, I need to know about her general condition (walking, eating well, recent weight loss, pain control, any chronic illness).

Any family history of breast cancer?

If her performance status is good and she is tolerating all the medicines well, she must continue the treatment. There are now few options left. That is to add Pertuzumab, Lapatinib, or TDM-1 (Ado-Trastuzumab emtansine). But all of these medicines are very expensive, and now at this stage, if there is diffuse metastasis, these medicines will not have a curative role but only a palliative role and may add some benefit only.

Another option is to start Eribulin injection (chemotherapy), which can be given after progression from Taxane and Anthracycline chemotherapy, or to start some other drugs as palliative chemotherapy.

The abdominal pain she is experiencing may be related to liver metastasis.

She has received treatment as per guidelines till now, except for Pertuzumab/TDM 1, which is very expensive, and few people can afford it. Unfortunately, as per the reports (attachment removed to protect patient identity), it is an advanced malignancy. Now the goal of the treatment is just palliation. Her performance status looks like 2 (ECOG).

The goal of the treatment should be to control her pain and to maintain intake (nutrition) and output (bowel and bladder habits). Provide her with psychological support and family support. She should also visit her oncologist for follow-up if she is not willing to undergo chemotherapy. At least hormonal treatment and Bisphosphonates are recommended and will be well tolerated (after consultation with a primary oncologist).

Lapatinib at this stage may even cause more toxicity than benefit (diarrhea, vomiting, hand-foot syndrome, and cardiac toxicity).

I hope I have answered your question.

Let me know if I can assist you further.

Regards.