Chemotherapy
followed by endocrine therapy for metastatic disease
Interview
with Neil Love, MD from Breast Cancer Update for Medical Oncologists,
Program 3 2000
Play
Audio Below:
Often
we’re taught classically that when patients present with metastatic
disease that’s ER-positive, that you should always, "burn
your anti-estrogen bridges before you go to chemotherapy."
And I think that’s true in the vast majority of cases, but
I think we all occasionally see the patient who has just bad breast
cancer that’s ER-positive. By that I mean, multi-organ system
disease, bulky disease, significant visceral involvement, impending
skeletal crisis, and in those scenarios I think there’s very
good rationale for the up front use of chemotherapy and the outback
use of hormonal therapy. And just last week a patient was admitted
to Memorial who fit that description and we had this discussion
– the Fellow and the resident and I – about why we would
not start, for example, with antiestrogen therapy. So within that
paradigm I can think of many patients in my practice who presented
with horrible breast cancer – with pathologic fractures, with
hypercalcemia, with liver failure and jaundice – who have been
induced to responses with chemotherapy and its attendant toxicities
who afterwards have been maintained for years and years and years
on agents like tamoxifen and Arimidex. So there’s that group
of patients too who have experienced the ravages – in terms
of symptoms of breast cancer – who were induced in response
with chemotherapy and then maintained with very high quality of
life subsequently for a long period of time with antiestrogen treatment.
These
perhaps are cases where the tempo of disease is so rapid, and I
think that the perception is that chemotherapy works faster. And
while we fully expect hormonal therapy to work in these circumstances
given the estrogen receptor positivity perhaps the time that it
takes, even if its six or eight or 10 or 12 weeks, is too long a
time and therefore, the more rapid response that one might see with
cytotoxic chemotherapy is justified under those circumstances
