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Track 6

DR LOVE: Had this patient received any endocrine therapy in the past?

DR MOSS: She told us tamoxifen had been prescribed, but she was convinced that it caused cancer, so she never took it. This made me a little nervous about using an oral therapy. She also had not received radiation therapy.

DR LOVE: Kevin, how would you think through an overall strategy for this patient?

DR FOX: You’re describing a situation that isn’t exactly life threatening but is symptomatically ominous. She itches and is probably fairly miserable. She looks at it in the mirror and is probably in distress.

On the surface, hormonal therapy appears to be appropriate because this is occurring 14 years after the initial diagnosis of ER-positive cancer, and it’s likely to be hormone sensitive. This, however, might be a situation in which I would try chemotherapy.

I would probably use paclitaxel/bevacizumab to make her feel better a little faster.

DR LOVE: Cliff, what about the selection of hormonal therapy?

DR HUDIS: I’d typically start with a nonsteroidal aromatase inhibitor. The EFECT study reassured us that after using a nonsteroidal aromatase inhibitor, we could use the steroidal aromatase inhibitor exemestane and obtain equivalent results to those we would obtain with fulvestrant.

I would have thought it would be better to proceed from the nonsteroidal aromatase inhibitor to fulvestrant, but the EFECT trial says it’s more or less equivalent to exemestane (Chia 2008; [6.1]).

After that, I would use fulvestrant if the patient remained a good candidate for hormonal therapy. I believe if the disease is hormone responsive, one should eke out a benefit for as long as possible. I suspect that this case would be likely to progress relatively quickly on hormonal therapy, and I would move on to chemotherapy then.

DR LOVE: Julie, would you discuss the trials that are evaluating the combination of fulvestrant with an aromatase inhibitor?

DR GRALOW: SWOG-S0226 (6.2) is a first-line trial in the metastatic setting that is evaluating an aromatase inhibitor with or without fulvestrant.

In the aromatase inhibitor-alone arm, at disease progression, we strongly encourage sequencing to fulvestrant. We can’t mandate it, but we’re trying to evaluate the combination versus the sequence of an aromatase inhibitor and fulvestrant.

We’re close to completing the accrual of about 690 patients. We’re awaiting the results from this and another similar trial to start the next adjuvant trial, in which we’re considering evaluating the combination.

DR LOVE: Let’s follow up with what happened with this patient.

DR MOSS: My bias is to use chemotherapy for these patients, but I didn’t feel that she would tolerate it. I decided to start her on fulvestrant.

I wanted to avoid pills because I was afraid she wouldn’t take them. I used a loading dose of fulvestrant, and she also received radiation therapy. Two to three weeks ago, her disease was in complete remission.

DR LOVE: We don’t hear much about responses to fulvestrant. Kevin, it seems as though most people use it pretty late?

DR FOX: I believe that’s part of what has cursed fulvestrant’s reputation. It’s never been used in circumstances in which it had much of a chance to shine. I believe it was a superb choice for this woman because of the concerns about compliance.