Handbook of Breast Cancer and Related Breast Disease by Katherine H. R. Tkaczuk MD Susan B. Kesmodel MD Steven J. Feigenberg MD

Author:Katherine H. R. Tkaczuk, MD,Susan B. Kesmodel, MD,Steven J. Feigenberg, MD
Language: eng
Format: epub
Publisher: Springer Publishing Company, Inc.
Published: 2016-12-09T05:00:00+00:00

Metastatic Breast Cancer

6

Katherine H. R. Tkaczuk, Paula Rosenblatt, Angela DeRidder, Syed S. Mahmood, Reshma L. Mahtani, Geetha Pukazhendhi, Susan B. Kesmodel, Jason Molitoris, and Randi Cohen

Despite an increase in detection of early-stage breast cancer over the past 30 years, approximately 5% to 10% of patients diagnosed with breast cancer present with de novo metastatic disease; in addition, up to 30% of lymph node (LN)-negative and 70% of LN-positive patients will eventually develop metastases (1,2). The primary goals of systemic treatment for MBC are palliation of symptoms, maintenance and improvement in quality of life, and prolongation of survival. These goals must be balanced against toxicities associated with treatment.

The 5-year survival of MBC has increased from 5% to 10% in 1990 to 26% presently based on Surveillance, Epidemiology, and End Results (SEER) data (3,4). In a series from MD Anderson, the median overall survival (OS) for patients with de novo stage IV and relapsed disease was 39.2 and 27.2 months, respectively (P < .0001) (5). Improved survival among patients with recurrent or newly diagnosed metastatic disease has been attributed to more aggressive management and the availability of effective therapeutics (6,7).

This chapter reviews the initial assessment and management of MBC. We review hormonal therapy (HT), combination hormonal and targeted therapy, single agent chemotherapy, and combination chemotherapy. Finally, while systemic therapy is the mainstay of treatment for MBC, there are certain situations in which radiation and surgery may play prominently in management for palliation of symptoms, maintenance and improvement in quality of life, and prolongation of survival. These situations are discussed at the end of the chapter.

INITIAL ASSESSMENT

At the diagnosis of metastatic disease, initial assessment should include:

•Tissue diagnosis of invasive breast cancer with markers (estrogen receptor [ER], progesterone receptor [PR], and HER2) is mandatory before systemic therapy is considered. We prefer to rebiopsy metastatic sites before final recommendations are made as a change in receptor status can alter treatment decisions in 20% of cases (8).

•History and physical exam. MBC patients who are being considered for systemic chemotherapy should be carefully evaluated in terms of clinical symptoms, physical exam (PE), and social support. The PE should include assessment of vital signs, performance status (PS), and comprehensive clinical exam. These assessments should continue with each prechemotherapy exam. Low PS is a predictor of poor survival, increased toxicity, and decreased chemotherapy response (9).

•Laboratories. Routine prechemotherapy labs should include a complete blood count (CBC) and comprehensive metabolic panel (CMP). Tumor markers (CA 15-3, 27.29) and circulating tumor cells (CTCs) can be considered but should never be used as a sole assessment of response to therapy. CTCs have prognostic significance (10).

•Imaging. We recommend baseline staging within 4 weeks of initiation of new systemic therapy and we do not routinely stage the central nervous system (CNS) unless there are specific symptoms to suggest CNS involvement. We recommend to stage with contrast-enhanced CTs of chest/abdomen/pelvis + bone scan or fludeoxyglucose (FDG) PET with diagnostic CTs initially.

•Genomic tumor tissue testing. Genomic tumor tissue testing looks to identify what may account for the

Download

Copyright Disclaimer:
This site does not store any files on its server. We only index and link to content provided by other sites. Please contact the content providers to delete copyright contents if any and email us, we'll remove relevant links or contents immediately.