• A 65-year-old woman was treated with lumpectomy, adjuvant CMF, radiation and five years of tamoxifen for a 1.3-cm, ER/PR-positive, HER2-negative breast tumor with negative nodes.
  
• A t age 70, the patient noted skin lesions on her hand, shoulder and abdomen that were biopsied and found to be metastases.
  
• Metastatic work-up revealed three bone lesions and a 2-cm hepatic lesion.
  
• Patient is asymptomatic and is receiving letrozole and a bisphosphonate.

Key discussion points:
	Treatment of the asymptomatic, elderly patient with ER-positive metastatic disease
	Efficacy and tolerability of fulvestrant

DR ZELKOWITZ: I saw this patient initially in 1998 when she was 65 years old. She had a 1.3-cm ER/PR-positive, HER2-negative tumor with negative nodes. After much discussion, she received adjuvant CMF, radiation to the breast and tamoxifen.

She recently completed her five years of tamoxifen and presented to the office for a routine follow-up visit. She had no complaints. On her way out she mentioned that she had a few funny "little things" on her skin. I've seen many skin metastases over the years, but these were very small and innocuous looking. I had done a complete physical examination and just passed by these lesions.

One was on the hand, another on the shoulder and one was on her abdomen. I wasn't sure what they were, so I sent her to her surgeon who removed them. Lo and behold, they turned out to be skin metastases.

DR LOVE: Were you expecting the surgeon to remove all three lesions?

DR ZELKOWITZ: No. I figured they would biopsy one. Frankly, I did not think this was metastatic disease. In retrospect, I wish he had left one so I would have a marker lesion.

So, obviously, this was metastatic disease. She is now almost 70 years old and totally asymptomatic. She spends a good part of her time on her boat with her husband. We repeated the ER/PR and HER2 assays, which remained the same - ER/PR-positive and HER2-negative. We did an extent of disease workup and found three solitary bone lesions - one in her sternum, one in her right hip with a negative plain film and a third in her rib. None of her bone lesions are symptomatic. She also has a 2-cm hepatic lesion. We didn't biopsy anything. Her chest CT was negative.

DR LOVE: Maria, how would you have thought through this situation?

DR THEODOULOU: She's asymptomatic, 70 years old and ER-positive. I would treat her with an aromatase inhibitor or fulvestrant.

DR ZELKOWITZ: We put her on letrozole and a bisphosphonate.

DR THEODOULOU: That's all reasonable. The question is: Would I treat her with chemotherapy? She had a five-year, disease-free interval, so I would be very comfortable treating her hormonally.

DR BURRIS: I would agree with that, too. The fulvestrant comment is interesting. My nurses have really gotten into the

mode of Medicare patients thinking about the question of prescription benefits and are aware of the coverage for fulvestrant, which we consider even more strongly if the patient is going to receive bisphosphonates.

I have a number of patients who come in and receive once-a-month zoledronic acid and fulvestrant. It's a shame. It's probably a greater cost to the system, but it saves the patient a lot of money.

There are plenty of Medicare patients out there who don't have that set-up, and fulvestrant works well in that scenario. I've had some very good results with fulvestrant, and certainly it's very reasonable to use.

Efficacy of Fulvestrant Compared to Anastrozole in Postmenopausal Women with Advanced Breast Cancer Progressing on Prior Endocrine Therapy

SOURCES: 1Parker LM et al. Proc ASCO 2002;Abstract 160 2Mauriac L et al. Eur J Cancer 2003;39(9):1228-33.Abstract. 3Howell A et al. J Clin Oncol 2002;20:3396-403 Abstract. 4Howell A et al. Proc ASCO 2003: Abstract 178 5. Osborne CK et al. J Clin Oncol 2002;20:3386-95. Abstract.

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