October 2011 Ask the Expert: Metastatic Breast Cancer Treatments and Strategies

October 1, 2011

During the month of October, Living Beyond Breast Cancer expert Erica L. Mayer, MD, MPH, answered your questions about new treatments and research for metastatic breast cancer and how to enhance your quality of life while living with metastatic disease.

Question: If a woman with metastatic breast cancer has been only on anastrozole (Arimidex) for bone mets, when it stops working would you go to another aromatase inhibitor next or fulvestrant (Faslodex)?

Dr. Mayer: For women with metastaticinfo-icon hormone receptorinfo-icon-positive breast cancer, treatment with endocrineinfo-icon agents is a preferable choice as these medicines can be quite effective with minimal toxicityinfo-icon

In general, there are a number of choices for endocrine therapyinfo-icon: non-steroidal aromatase inhibitors (AI) such as anastrozoleinfo-icon (Arimidex) and letrozoleinfo-icon (Femarainfo-icon), steroidal aromatase inhibitors such as exemestaneinfo-icon (Aromasininfo-icon), tamoxifeninfo-icon, and fulvestrantinfo-icon. All of these agents are very active against metastatic breast cancer. Selecting which agent to use often depends on prior exposures—for example, did the tumorinfo-icon recur while the woman was taking one of these therapies and would then be considered resistant? Or, does the woman have a preference for oralinfo-icon versus injectioninfo-icon therapyinfo-icon

For a woman whose tumor progresses on anastrozole, options include tamoxifen, exemestane or fulvestrant. The question of exemestane versus fulvestrant has specifically been addressed in a clinical trialinfo-icon in which women progressing on a non-steroidal AI were randomly selected to get either exemestane or fulvestrant. Results from that study showed no difference in outcomes between the arms. Therefore, a decision in this setting should be made based on a woman’s preference for method of administration, and the woman can feel confident that either choice is acceptable.

Question: Would it be fair to say the research areas of greatest hope are stem cells and vaccines?

Dr. Mayer: The study of both cancer stem cells and cancer vaccines is of significant interest, and multiple laboratories worldwide are investigating these topics. Much of this work has broadened our knowledge of cancer cellinfo-icon biology but has not yet translated into findings with a direct impact on women and their treatment. 

There are many other important areas of breast cancer research as well. Other topics pursued in research laboratories include learning more about how cells respond to growth signals, understanding how to target the communication that happens inside cancer cells and learning more about how cancer cells interact with their environment inside the body. 

Clinicalinfo-icon research areas of interest include evaluating the safety and activity of new cancer therapies as part of clinical trials, and exploring the effect of a breast cancer diagnosisinfo-icon and subsequent treatment on a woman's quality of lifeinfo-icon and emotional status. Population studies look at possible reasons people develop cancer and try to identify activities which can be protective against cancer. All of these arenas are important cancer research topics and can lead not only to better understanding of cancer biology, but also to improvements in cancer preventioninfo-icon and treatments.

Question: Do you believe that trastuzumab (Herceptin) should be continued indefinitely if you have stage IV disease? Or do you take a break after 2 years? I'm 38 and NED (no evidence of disease) after bone mets, but want to make sure I don't harm myself with this treatment every 3 weeks.

Dr. Mayer: Congratulations on doing very well! The use of trastuzumabinfo-icon (Herceptininfo-icon) for HER2-positive breast cancer has certainly revolutionized the treatment of stageinfo-icon IV (metastaticinfo-icon), HER2-positive breast cancer, and increasingly we see women with HER2- positive cancer who are living and thriving with advanced disease. Therefore, your question about duration of trastuzumab is increasingly common. 

Unfortunately, we do not currently have data from clinicalinfo-icon trials to guide these decisions. In practice, many of us will continue trastuzumab indefinitely in the setting of metastatic, HER2-positive disease. We also continue cardiac monitoring, often on an every 4-6 month basis. Anecdotally, there does not appear to be any long-term toxicityinfo-icon from extended exposure to trastuzumab. Therefore, I would suggest continuing with trastuzumab for now, and I wish you best of luck with your treatment!

Question: What is the maximum reasonable amount of time to take to decide on a treatment plan after one learns of a metastatic breast cancer diagnosis?

Dr. Mayer: Being diagnosed with metastaticinfo-icon breast cancer is a life-altering experience; it often feels like an emergency requiring immediate action. Occasionally there are situations when beginning therapyinfo-icon right away is necessary. However in the majority of situations, there is usually adequate time to learn more about the new diagnosisinfo-icon and visit with doctors while making a decision about how to proceed. This process can also include getting second opinions regarding treatment options or taking time to consider enrolling in a clinical trialinfo-icon

Overall, it can be worthwhile to take time to learn about your treatment choices and become fully educated. However, as each woman’s situation is different, there should be ongoing discussion with your doctor about the safety of waiting before making a final decision.

Question: Are there any general guidelines that you give your patients regarding making decisions about treatment options once there is distant recurrence?

Dr. Mayer: Many important decisions come up when faced with a metastaticinfo-icon breast cancer diagnosisinfo-icon, and no rule book tells you what’s right and what’s wrong. 

One of the most important things to start with is good communication with your treatment team as well as at home with your friends and family. You want to make sure everyone knows your preferences, values and goals as you make decisions together. 

It’s important to feel well-informed. Although the Internet is full of cancer information, you have to use it wisely and try to stay with sites that are safe and reviewed by cancer specialists. 

Always consider getting a second opinion if you are confused about what to do next. Your own doctor will not be offended if you visit with another specialistinfo-icon, and often an outside opinion can help put things in perspective. 

Ultimately, there are often many treatment options available for metastatic breast cancer. Being well-informed and communicating with your treatment team can often lead to effective and satisfying decisions.

Question: I have triple-negative breast cancer. How long can someone be on paclitaxel (Abraxane) for example, or any of the other chemos?

Dr. Mayer: In general, you will want to try to stay on therapies for as long as possible to get maximum benefit. Indications that it’s time to change therapies include clear evidence of cancer progressioninfo-icon, either on a scaninfo-icon or because of worsening symptoms, or the development of unbearable side effects which cannot be fixed. 

Although monitoring tumorinfo-icon markers or other blood tests to determine cancer status can help gauge the effectiveness of a therapyinfo-icon, decisions about whether or not to change treatments should not be based entirely on trends in markers. Some chemotherapies such as doxorubicininfo-icon (Adriamycin) can have increasing toxicityinfo-icon which can result in permanent body damage over time. But for most chemotherapies, including paclitaxelinfo-icon, treatment can continue until it no longer works or until a side effectinfo-icon such as neuropathyinfo-icon makes it too difficult to continue the medication.

Question: Since the PARP inhibitors have not lived up to early expectations, what other new treatments do you anticipate for triple-negative breast cancer?

Dr. Mayer: Although the outcomeinfo-icon of research on the agent iniparibinfo-icon has been disappointing, other PARPinfo-icon inhibitors, including veliparib and olaparibinfo-icon, continue to be studied in both triple-negative breast cancerinfo-icon and in cancers that develop in women with BRCA1info-icon or BRCA2info-icon geneinfo-icon mutations. Other targeted agents under study for triple-negative breast cancer include treatments that block cellinfo-icon surface receptors, specialized proteins that take part in communication between the cell and the outside world, or therapies that disrupt communication inside cancer cells. 

There is also interest in examining the activity of certain types of chemotherapies, including “platinum” chemotherapyinfo-icon, for triple-negative breast cancer. The majority of this work is being done in clinicalinfo-icon trials; therefore women with triple-negative breast cancer are strongly urged to enroll in a trial to get exposure to these new medications.

Question: I have had metastatic disease since Nov. 2005. Up until last fall, it had been confined to the spine (one disc at a time). Since last fall, my bone scans have either shown complete healing to affected areas or stabilization in two vertebrae. However, last fall two small lesions were found on my liver. They have shrunk since then. I am currently on paclitaxel (Taxol) and bevacizumab (Avastin). Has there been any research on liver ablation with breast cancer? I know that it is used for liver and colon cancer, but how about breast cancer?

Dr. Mayer: Congratulations on 6 years living with metastaticinfo-icon breast cancer! It sounds like you have done well on your treatments to date.

As you mention, liver directed therapies, local therapies directed to metastatic cancer spots in the liver, have a well-defined role in the treatment of some solid tumors, notably colon cancer. The possible benefit of liver-directed therapyinfo-icon in metastatic breast cancer is not well studied. 

Some data have been published describing small numbers of women who have received tumorinfo-icon ablationinfo-icon for treatment, however these studies contain no appropriate comparison group. Therefore it is not known if having treatment to the liver improves outcomes for these women versus continuing on with more traditional treatments such as chemotherapyinfo-icon

In general, liver-directed therapies outside of a trial are not encouraged, especially not while receiving bevacizumab, which could increase the risks associated with the procedure. But you should feel comfortable discussing this topic in further detail with your cancer doctor.

Question: I am a 9-year survivor of metastatic inflammatory breast cancer. A recent PET scan shows activity in my lung. I never want to take chemo again, ever. What treatment is available today? My chemo treatment stopped 10/2010 because of heart damage. For the first time in 9 years, during the last 10 months my cancer has not returned except for the recent spot on my lung. Any advice?

Dr. Mayer: Congratulations to you as well on 9 years of living with metastaticinfo-icon breast cancer! 

Whenever there is a new finding on scans, it’s important to consider all treatment options. Chemotherapyinfo-icon for metastatic breast cancer is usually a very different experience compared to receiving adjuvant chemotherapy after surgeryinfo-icon. Chemotherapy dosing and scheduling for metastatic disease are designed to maximize treatment activity against the cancer while minimizing any side effects related to the treatment. This often includes schedules offering small doses on a weekly schedule. 

If significant side effects develop, changes in doseinfo-icon and schedule often can overcome them. If not, moving to an agent with a different side effectinfo-icon profile can help. Also, changes in heart function related to trastuzumabinfo-icon appear to resolve once treatment is held. Rechecking heart function would be important to do right now. 

Treatment options for HER2 positive breast cancer continue to evolve, and many new targeted biologicinfo-icon agents are available as part of clinicalinfo-icon trials. It is important to review with your doctor what treatments are available to you at this time and what opportunities exist through clinical trials.

Question: I have invasive lobular breast cancer which has metastasized to my bones and stomach. I started capecitabine (Xeloda) about a month ago, and it seems that it is starting to work. I have weekly bloodwork and will have a CT scan after 3 months. Any other suggestions as far as monitoring?

Dr. Mayer: Capecitabineinfo-icon is a fine choice for metastaticinfo-icon lobular carcinomainfo-icon and can often be quite effective. Close monitoring by bloodwork, visits with your treatment team for examination andperiodic radiologyinfo-icon scans sound like a very appropriate start. Once you are settled into treatment and tolerating it well, you could consider decreasing the frequency of bloodwork to every 3-4 weeks. Restaging every 3-4 months is acceptable as well.

Question: Can I take vitamin D while I am under treatment with chemotherapy?

Dr. Mayer: In general, basic supplements, including multivitamins, calcium, and standard doseinfo-icon vitamin D, are fine to take during chemotherapyinfo-icon. Some supplements or high dose vitamins have the potential to negatively interact with traditional cancer medicines. Additionally, exposure to some supplements can irritate the liver, making it harder to safely administer chemotherapy. 

It is very important to report any supplements you are taking to your doctor so you can work together to ensure that taking the supplements in combination with chemotherapy is safe.

Question: I was diagnosed with metastatic breast cancer in February 2010….I finished with chemo and trastuzumab (Herceptin). I just started having my period about 4 times since I finished chemo. Will my period ever return to normal? Now it comes every 2 1/2 months and runs for 2 weeks. I’m on my period now and it has lasted for more than 2 weeks— it started slightly heavy then diminished to spotting and then back to slight bleeding, then back to spotting again. Is this normal, or is something else going on?

Dr. Mayer: When a woman is premenopausalinfo-icon, exposure to chemotherapyinfo-icon can affect ovaryinfo-icon function, causing a change in the timing and nature of periods. Depending on a woman’s age and type of chemotherapy exposure, there is a chance that chemotherapy can lead to temporary or permanent menopauseinfo-icon. If the effect is temporary, periods can be irregular after the ovaries wake up and may or may not eventually return to normal cycles. If a woman has very heavy vaginal bleeding, evaluation by a gynecologist is suggested.

Question: After my metastatic breast cancer diagnosis, I’ve tried anastrozole (Arimidex), exemestane (Aromasin), tamoxifen, fulvestrant (Faslodex) and am currently on letrozole (Femara). My numbers are starting to creep up with the Femara, so I’m afraid my doctor is going to put me on capecitabine (Xeloda). Are there other hormone blockers out there when it’s time to switch meds again?

Dr. Mayer: Primary endocrine therapyinfo-icon choices for hormone receptorinfo-icon- positive breast cancer include non-steroidal aromatase inhibitors (anastrozoleinfo-icon, letrozoleinfo-icon), steroidal aromatase inhibitors (exemestaneinfo-icon), tamoxifeninfo-icon and fulvestrantinfo-icon. Megestrolinfo-icon (Megace) is occasionally considered, however it sometimes can cause undesirable side effects.

Outside of clinicalinfo-icon trials, women often transition to chemotherapyinfo-icon after finishing these endocrineinfo-icon therapies. However a growing number of clinical trials add new oralinfo-icon biologicinfo-icon therapies to previously used endocrine therapy in order to overcome tumorinfo-icon resistance. Alternatively, some trials offer treatment just with an oral biologic agent without the use of chemotherapy. Therefore, you could seek out trial enrollment as a next step after progressioninfo-icon on letrozole.

Question: When I was first diagnosed with mets, a second opinion doctor in NY told me that her patients live an average of 5-7 years after diagnosis, which of course floored me. I’m almost in my 4th year and pretty much feel normal physically. Is there new intelligence out there on what our life expectancies are with all the new meds?

Dr. Mayer: Congratulations on doing so well for 4 years and counting! Determining life expectancy with metastaticinfo-icon breast cancer is tricky, as population statistics may not reflect what happens to an individual person. Furthermore, the ongoing development of better therapies for metastatic breast cancer has definitely led to improvements in survival. 

We increasingly are seeing women do well for much longer than expected. In general, it is not possible to give updated life expectancy numbers, but we certainly hope that we continue to see more and more women living and thriving while being treated for metastatic disease.

Question: What is the current treatment standard for muscle/bone/joint pain resulting from taking aromatase inhibitors during prolonged periods (e.g. >3 years, >5 years, >7/8 years, etc.)?

Dr. Mayer: Experiencing joint discomfort while taking aromatase inhibitors is a common phenomenon; some research even suggests it may reflect favorable activity of the medicineinfo-icon in the body! However, managing this side effectinfo-icon can be challenging. 

Recommended techniques include use of non-steroidal inflammatory agents, stretching, exercise and acupunctureinfo-icon. Ongoing investigations are looking at new complementary techniques which may be of benefit. Sometimes changing to another aromatase inhibitorinfo-icon can make a difference. Good communication with your doctor about your degree of discomfort will allow you to work together on the best treatment strategies.

Question: Is there any anticipated change(s), as a result of clinical trials or other, in future treatment for pain?

Dr. Mayer: Management of cancer-related pain has improved over the past several years. One of the biggest improvements has been recognizing the need to monitor pain more closely. In many doctors’ offices, evaluating pain has become as commonplace as checking blood pressure. 

Additionally, a multidisciplinaryinfo-icon team approach is being used more often in pain management. This means a group of providers— including medical oncologists, oncologyinfo-icon nurses, pharmacists, pain and palliative careinfo-icon specialists, radiationinfo-icon oncologists, and social workers—work together to manage a woman’s pain using a variety of techniques beyond just pills. 

Ultimately, the most successful pain management occurs when women and their doctors are able to communicate openly and honestly about symptoms, needs and options.