The enclosed audio program contains highlights from two case-based daylong CME
meetings our group hosted for medical oncologists in Los Angeles and New York
City. Like all of our live events, the primary purpose of these gatherings was for us
to interact with physicians in practice to better understand their education needs.
To better accomplish this goal, we commonly utilize an innovative wireless “chat
room” setup that provides each attendee with a portable computer throughout the
event. This allows participants to continuously provide input to our faculty panel,
but even more importantly, it encourages them to pose questions that are usually
answered by investigators as part of the meeting or typed in the chat room. Below,
find a sampling of the most common queries and comments that emerged, many of
which are discussed in the enclosed program.
Adjuvant and neoadjuvant endocrine and monoclonal antibody therapy |
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How do you approach endocrine therapy in patients with chemotherapy-induced
menopause? |
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In the absence of randomized trial data, please comment on the use of
adjuvant tamoxifen versus an AI with goserelin in premenopausal patients. |
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It is recommended that tamoxifen not be given at the same time as adjuvant
chemotherapy; is the recommendation for AIs different? Can AIs be used
concurrently with radiation therapy? |
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Is there any value in administering an AI for two years and then switching to
tamoxifen? |
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Is tamoxifen dead for postmenopausal patients? |
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A lot of the safety benefit of an AI is based on decreased gynecological
symptoms. Is the toxicity profile of an AI better for women who have had a
hysterectomy? |
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Should an AI be used in the treatment of DCIS instead of tamoxifen? Are we
justified in using anastrozole as chemoprevention for patients at high risk for
breast cancer? |
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Was it the weight loss or the decreased fat intake that led to the reduced
breast cancer relapse rate in the WINS trial? Why were the benefits seen
mainly in the patients with ER-negative disease? Is there any reason not to
believe that a low-fat diet might be beneficial to patients with other types of
malignancies? |
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Should the impressive results of the WINS trial of dietary fat reduction be
discussed with patients at this point? If we had seen these results in a study
in which patients took a drug to achieve this, we would have seen a lot more
excitement about them. |
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Do aspirin or statins decrease the risk for stroke or MI in patients receiving
anti-estrogen therapy? For a patient with an adverse lipid profile and
osteoporosis, which aromatase inhibitor do you use? |
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Do you use the Oncotype DX in your patients? Is it covered by insurance? |
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What do you recommend for osteoporosis prevention when using an AI, and at
what point do you stop the AI based on a change in bone density? |
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If a woman already has osteoporosis before starting anastrozole, what is your
choice of bisphosphonate for her? |
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If you switch from tamoxifen to an AI after two years, do you continue the AI
for three years or five years? Can a patient be at low enough risk of relapse
not to switch to letrozole after five years of tamoxifen? |
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Has anybody looked at the use of COX-2 inhibitors in patients with letrozoleinduced
arthralgias? Perhaps this, rather than the altered lipids that letrozole-induced, contributed to the high incidence of cardiac death in the BIG study. |
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Are the musculoskeletal side effects the same with all AIs? In other words, if
a woman is taking one AI and not tolerating it due to these symptoms, might
she do better with another AI? Why do AIs cause these symptoms? |
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How often do you measure bone density in patients who are on AIs? Do you
put them on bisphosphonates and calcium supplements if they have osteopenia? |
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Would cardiac echo be more accurate than a MUGA scan in determining LVEF
in patients on adjuvant trastuzumab? How about adding a cardioprotective
agent? |
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Is it reasonable to use dose-dense adjuvant chemotherapy with trastuzumab? |
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What is the difference between AC followed by paclitaxel/trastuzumab and AC
followed by docetaxel/trastuzumab? Does docetaxel/trastuzumab result in less
cardiac toxicity? |
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Do you give adjuvant trastuzumab weekly or every three weeks? |
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Would you use trastuzumab as part of neoadjuvant therapy in which the nodal
status isn’t assessed pathologically? If so, would you look at something like
PET to assess the axilla? |
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What is the explanation for the high incidence of brain metastases in women
on trastuzumab? Is this due to blood-brain barrier issues or the development
of resistant clones? |
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How reliable is IHC for assessing HER2 status? When must we use FISH? |
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Close monitoring of cardiac function is recommended for patients receiving
trastuzumab and chemotherapy. In fact, monitoring neither prevents nor
predicts congestive cardiomyopathy; it merely confirms it. |
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What medical options are available for the woman with HER2-positive breast
cancer who demonstrates declining EF while on trastuzumab? |
| Systemic therapy for metastatic disease |
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The ECOG-1193 study shows no advantage to combining paclitaxel/doxorubicin.
However, this does not mean other combinations are not superior. There
is little reason to think AT would be superior (no synergism, overlapping toxicities,
inability to administer full therapeutic doses in combination). On the
other hand, a rationale does exist for regimens such as DC and GT. |
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One of the goals of chemotherapy for metastatic disease is palliation. In
general, response (or control of disease) is associated with palliation. As combination
regimens have higher response rates (and better control of disease),
one can assume they will be associated with better palliation too. |
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Are data available on gemcitabine/capecitabine for metastatic breast cancer? |
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Does anyone use the European approach of starting capecitabine at full dose
but closely monitoring the patient during capecitabine administration and
reducing the dose in the middle of a cycle? |
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The cost of capecitabine is an issue for patients because many do not have
prescription coverage and are ineligible for patient assistance programs. This
is a common reason for patients preferring IV chemotherapy to capecitabine
despite physician recommendation of capecitabine. |
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Some California senior-care HMOs cover only generic forms of oral medications,
and for both capecitabine and etoposide, no generic form exists, and
they are not covered. This is an excuse. Are there any recommendations for
dealing with this issue? |
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We make a big fuss about the lack of crossover design in many chemotherapy
trials for metastatic disease. However, for other tumor sites (eg, colon, lung),
combination therapy is the standard, with no crossover design studies. |
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Sometimes when we change the dose of capecitabine, pharmacists see the
prescription for 14 days given every 21 days, and either the patient or the
pharmacy seems to be confused as to how many pills constitute a “30-day
supply.” Also, if we have prescribed 500-mg tabs and want to change to the
smaller-dose tabs halfway through the month, we have difficulty doing this
because preauthorization from insurance companies takes four to five days or
longer if they require a dictated note to make any changes. |
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What would your choice of therapy be for patients who had received AC/paclitaxel/
trastuzumab as adjuvant therapy and then relapsed after one year?
Would you re-treat with trastuzumab-based therapy or go to antiVEGF-based
therapy? |
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A main reason for continuing trastuzumab beyond progression is the preclinical
synergism between trastuzumab and many chemotherapy drugs. Do any
preclinical data show that tumors that become resistant to trastuzumab still
benefit from continuing trastuzumab? |
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Does the degree of HER2 amplification matter? Isn’t positive just positive? |
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What is the role of tumor markers, bone scans, CT scans, etc, in the routine
follow-up of breast cancer? NCCN has issued guidelines, but are they being
followed? |
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Has capecitabine been combined with weekly paclitaxel in any studies? Do
you think this regimen would make any difference compared to three-weekly
paclitaxel in terms of efficacy and safety? |
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Is there a rationale for combining fulvestrant with an AI? Do any preclinical
models show synergism? |
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Is there an optimal dose and/or schedule for fulvestrant? Should patients be
“loaded” with a loading dose? |
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What is your first choice of hormonal therapy for the premenopausal patient
with metastatic, ER-positive disease? |
