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You are here: Home: BCU Nurses 2004 Vol 2 Issue 1: Patient Case Summaries
| Clinical Issues: |
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Chemotherapy-related side effects compared to endocrine therapy |
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Research background for selection of adjuvant hormonal therapy for postmenopausal women with ER-positive tumors |
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Differences between
side-effect profiles of
anastrozole and tamoxifen |
Mrs S: A 67-Year-Old Retired Schoolteacher Receiving Adjuvant Treatment
Mrs S was diagnosed with ER-positive breast cancer three years ago. Although presented with the option of lumpectomy, Mrs S decided to undergo mastectomy. An axillary node dissection revealed one positive lymph node. Following her primary therapy, Mrs S elected six cycles of adjuvant CEF (in lieu of a doxorubicin-containing regimen) to potentially decrease the likelihood of toxicity. Despite this decision, she experienced alopecia, constant nausea, weight gain and profound fatigue. At the completion of adjuvant chemotherapy, Mrs S began hormonal therapy with anastrozole and continues to receive this treatment with minimal side effects other than arthralgias relieved by nonsteroidal anti-inflammatory drugs.
| Patient Perspective: Mrs S |
“Chemotherapy was not pleasant. It was a very traumatic experience and the side effects were not good. Besides the hair loss, which was horrible, I was constantly nauseous, had headaches and was tired all of the time. I’m the type of person who can take on any problem, but when I was on chemotherapy my mind was willing but my body just wasn’t able. I had no energy and I didn’t care about anything. All I did was sleep. After chemotherapy, Dr Franco wanted me to start hormonal therapy. She explained to me the pros and cons, and based on what she told me, anastrozole seemed like a more viable choice than tamoxifen.
Unfortunately, people in my family have been on tamoxifen and ended up having hysterectomies, blood clots and all sorts of problems, so I felt anastrozole was a safer choice for me. I have experienced some joint pain with anastrozole. It started a couple of months after I started taking the drug. Some days it’s better and some days it is worse. I think it depends on the weather. Usually, I just take ibuprofen or something like that and then it’s okay.” |
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| Clinical Issues: |
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Sequencing of hormonal therapies after progression on tamoxifen |
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Role of chemotherapy in the elderly patient with ER-positive metastatic disease |
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Quality of life for patients on hormonal therapy for metastatic disease |
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Patient compliance with oral endocrine treatments |
Mrs T: An 80-Year-Old Widow with Metastatic Disease
Mrs T was diagnosed with breast cancer at the age of 69. At that time she was working part-time and caring for her husband who was being treated for Parkinson’s disease. During her initial course of therapy, Mrs T underwent mastectomy, axillary dissection, radiation therapy, 6 cycles of adjuvant CAF chemotherapy and then received tamoxifen. She remained cancer-free for four years until a routine pelvic x-ray following an automobile accident revealed bony metastases in the hip. Mrs T was treated with pelvic irradiation and was started on anastrozole and pamidronate. The pain subsided and she remained on anastrozole for more than three years. At that time, a follow-up MRI conducted because of back pain revealed metastases in the lumbar spine. Anastrozole was discontinued, and monthly intramuscular injections of fulvestrant were initiated. The patient experienced relief of the back pain and remained asymptomatic and fully functional on fulvestrant for two years. In late 2003, another MRI following complaints of further pain in the upper back revealed a new metastasis in her thoracic spine. Two months later her treatment was switched from fulvestrant to the aromatase inhibitor exemestane, which has ameliorated her back pain.
| Patient Perspective: Mrs T |
“I had been receiving anastrozole for about three or four years without any problems when I began to have pains in my back similar to the original pain I had in my hip. Dr Vogel ordered the necessary tests, which showed that the disease was getting worse. Based on these findings, he felt that the anastrozole had stopped working so he put me on fulvestrant. I received two fulvestrant injections every month, one on each side. They were simple. I’ve never been a pill taker, and with the injection, I didn’t have to worry about taking a pill every day. I didn’t mind the injection at all. I really didn’t have any discomfort or side effects from the medication either, and it wasn’t too long —maybe just a couple of months — before the pain in my back started getting better.” |
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| Clinical Issues: |
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Algorithm for the treatment of ER-positive, HER2-positive breast cancer |
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Use of trastuzumab in combination with hormonal therapy |
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Continuation of trastuzumab after progression |
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Importance of enrolling patients in clinical trials |
Mrs M: A 50-Year-Old Grandmother with HER2-Positive Hepatic Metastases
In 1994, at the age of 40, Mrs M was diagnosed with ER-positive, HER2-positive breast cancer. She was premenopausal and received adjuvant chemotherapy, tamoxifen and ovarian ablation. In 1997, Mrs M began to feel ill and she returned to her oncologist. Multiple metastases were discovered in her liver. Because her tumor overexpressed HER2, Mrs M’s oncologist recommended enrollment in a clinical trial testing the efficacy of the anti-HER2 antibody, trastuzumab, as a single agent. Trastuzumab was given weekly and she experienced no side effects. The hepatic lesions decreased in size and the patient felt well again. After three years, the liver metastases progressed and anastrozole was added to the trastuzumab, resulting in another response. Mrs M continues to receive her trastuzumab infusions every week and takes her anastrozole daily. She has been essentially without symptoms, living with metastatic disease for eight years.
| Patient Perspective: Mrs M |
“When I found out my cancer had come back, Dr Vogel sat down with me and discussed the different treatment options. He told me about chemotherapy and also about a clinical trial he was running with trastuzumab. I had heard a lot about chemotherapy and was aware that it would make me feel sick. I am the type of person who likes to knock on different doors and not necessarily go through the last door first. I would rather start with the first door. In this case, starting with trastuzumab and avoiding chemotherapy was the door I thought I should go for first.” |
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| Clinical Issues: |
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Long-term survival with ER-positive breast cancer |
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Salvage therapies for ER-positive metastatic breast cancer |
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Chemotherapeutic options for the symptomatic elderly patient |
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Counseling patients on end-of-life issues |
Mrs B: An 83-Year-Old Retired Nurse with a 22-Year History of Breast Cancer and Nine Years of Treatment for Metastatic Disease
Mrs B was first diagnosed with breast cancer 22 years ago. For the past nine years, she has had metastatic disease. She has received multiple hormonal therapies, including anastrozole and fulvestrant, with good response. Like many women with ER-positive breast cancer, endocrine therapy finally lost its effectiveness, and Mrs B subsequently received a number of chemotherapeutic agents. Currently, she has highly symptomatic pulmonary metastases, which is significantly interfering with her lifestyle.
| Patient Perspective: Mrs B |
“When I sit in the treatment room I often listen to the conversations of other patients and sometimes I just want to tell them that we are in this for the long haul. I am in my twenty-second year, and these women will have better chances than I had because of all of the research and innovation that has gone on. There will be drugs available to them that were not available to me. I really did not expect to live this long. I feel lucky, I really do.” |
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