CHEMOTHERAPY VS ENDOCRINE THERAPY VS TRASTUZUMAB FOR THIS PATIENT

The options in this patient would be to either go with hormonal therapy or with trastuzumab. There has been some concern that HER2-positive patients might have a lower likelihood of responding to hormonal therapies, but the studies that have looked at that have been somewhat discordant. A majority of the studies have shown some degree of resistance, but there are some that have not shown any impact at all.

So, I don’t use HER2-neu positivity to exclude patients from hormonal therapy. I still think that they are appropriate candidates for hormonal therapy, but I do tell them that there is some literature to suggest their likelihood of response might be a little bit lower. In an asymptomatic patient who is going to be followed closely, I think it is reasonable to start with the hormonal therapy.

One reason I would start with a hormonal therapy versus trastuzumab is convenience. Instead of a weekly intravenous infusion,the patient can be on an oral drug.Another reason is safety — even though trastuzumab is a very safe drug, there is a small risk of cardiac toxicity, and there are other side effects. The safety profile slightly favors a hormonal therapy.

—Debu Tripathy, MD

CHEMOTHERAPY VS ENDOCRINE THERAPY

With regard to chemotherapy, there is no information to suggest that this patient would be better off in the long term starting with chemotherapy. No data suggest that survival is enhanced by starting with aggressive therapy. In fact, if you extrapolate the findings of the very intensive bone marrow transplant, we don’t see an advantage. Many oncologists are now gravitating towards starting therapy with less toxic treatments as long as the likelihood of response is in the same ballpark. I think that this patient’s likelihood and duration of response were probably about the same with the hormonal therapy as with chemotherapy.

This patient’s past medical history entered somewhat into our decision about which hormonal therapy to use first. She was treated four years ago — in the “pre-first-line aromatase inhibitor days,” before we had the first-line data. At the time it was only indicated for second-line therapy, and I would only have considered it first-line in someone with a contraindication to tamoxifen. Given this woman’s history of deep venous thrombosis, tamoxifen was a much less appropriate drug because of the thrombogenic potential.

—Debu Tripathy, MD

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