let’s talk about metastatic breast cancer: answers to your most pressing medical and
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]. LET’S TALK ABOUT METASTATIC BREAST CANCER: Answers to Your Most Pressing Medical and Psychosocial Concerns. Mission. communities to increase the quality and quantity of life for women diagnosed with breast cancer ages 40 and under. - PowerPoint PPT PresentationTRANSCRIPT
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LET’S TALK ABOUTLET’S TALK ABOUT METASTATIC BREAST CANCER: METASTATIC BREAST CANCER: Answers to Your Most Pressing Answers to Your Most Pressing
Medical Medical and and
Psychosocial Concerns Psychosocial Concerns
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MissionYoung Survival Coalition (YSC) is the premier international organization dedicated to the critical issues unique to young women and breast cancer. YSC works with survivors, caregivers, and the medical, research, advocacy and legislative communities to increase the quality and quantity of life for women diagnosed with breast cancer ages 40 and under.
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Tonight’s Speakers
Generosa Grana, MDProfessor of Medicine, CMSRU
Director, Cooper Cancer Institute&
11-Year Stage IV Survivor Dikla Benzeevi
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• Presentation– Sites of Disease– Prognosis
• Treatment Options– Hormonal Therapy– Chemotherapy– Biologic Therapy– Radiation
• Supportive Measures– Bisphosphonates, etc.
Metastatic Breast Cancer
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• Defining goals
• Communicating with oncology team & with family
• Early use of palliative care / supportive care resources
• Use of psychosocial support services
Important Elements
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Determining Factors:
• Sites of recurrence– Skin, nodes>pleura, bone >lung, liver– Brain > meninges
• Time from diagnosis to recurrence
• Type of tumor (ER, HER2/neu)
• Significant improvements with available new drugs (chemo, hormonals, biologics)
Metastatic Disease Prognosis
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Current selection of therapy• Based on sites of disease – urgency• Previous therapy (prior anthracyclines, taxanes,
type of hormonal therapy)• Pre-existing toxicity (neuropathy,
cardiomyopathy, other)• Menopausal status• ER / PR status• HER2/neu status• Patient goals (weekly vs. Q 3 week, oral vs. IV,
hair loss vs. not, etc) (compliance)
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• Palliation of symptoms
• Improve survival
• Tumor response
Goals of Treatment
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Systemic Treatment Options
Metastatic Disease
ER &/Or PR +Non-life threatening
Disease--
Hormone Therapy
ER- / PR- Her 2 neu –
--ChemotherapySingle AgentCombination
Her 2 – neu +
Er- / Pr---
Her2 targeted + Chemo
Er &/or Pr +--
Hormone RxHormone +
Herceptin alone
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Diagnosis of metastatic breast cancer
Determination of sites and extent of diseaseAssessment of HER2, HR status, disease-free interval, age, and menopausal status
No life-threatening disease,hormone responsive
Hormone unresponsive orlife-threatening disease
First-line hormonal therapy First-line chemotherapy
ResponseNo response
Second-line hormonal therapy
Second-line chemotherapy
Progression
Progression
Progression
Progression
Third-line hormonal therapy
Response
No response
No response
Third-line chemotherapy
Supportive care
Management of Metastatic Breast Cancer
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• Chemotherapy vs. Hormone Therapy
• Single Agent vs. Combination Therapy
• Sequence of agents
• When to integrate hormonal agents if ER+
• Sequence in HER2/neu + disease
• Approach to triple negative disease
• Approach to BRCA1/2 + disease
Debates
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What Are The Options Following Tamoxifen?
First treatment
Second treatment
Fourth treatment
Third treatment
Tamoxifen
FulvestrantNonsteroidal AI
Nonsteroidal AI Fulvestrant Steroidal AI
Steroidal AI Steroidal AINonsteroidal AI
Other options for subsequent therapy: progesterone agents, high-dose estrogen, AI + everolimus, clinical trial
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Premenopausal• Antiestrogens (SERMS)
– Tamoxifen
– Toremifene
• Ovarian Suppression
• Antiestrogens + os
Postmenopausal• Antiestrogens (SERMS)
• Aromatase Inhibitors
• SERDS (Faslodex)
• Progestins
• Androgens
• Estrogen
Hormonal Therapy Options for Metastatic Disease
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Recent Additions
• Chemotherapy:– Halaven (erebulin)– Others in testing
• HER2/neu based therapy:– Pertuzumab– Kadcyla– Neratinib – in testing
• Hormonal therapy:– Faslodex– Exemestane + Afinitor
• Novel compounds– Parp inhibitors– Vaccines– Others
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• Genetic profile of tumor– Caris, individual institutional research
programs
• Genetic profile of host – metabolizing pathways???
• Better understanding of pathways and relationship between pathways
Future Choices
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5-AzacytidineDecitabineFazarabine
Depsipeptide
OxaliplatinGemcitabine
Irofulven
Paclitaxel DocetaxelDolastatin Ixabepilone
Benzoylphenylurea
Bortezomib
CC49LMB-9
Mab CO17-1A
Survival Factors(eg, IGF1)
Hormones(eg, Bombesin)(eg, Estrogen)
TipifarnibBMS-214662
Growth Factors(eg, TGF)
ErlotinibSU6668
SexaminibGefitinib
TrastuzumabLapatinib
ECM
Cilengitide
Cells
Bryostatin-1Everolimus
Temsirolimus
BortezomibCytokines(eg, ILs, IFNs)
WNT
Flavopiridol
IL-4IL-12IFN
UCN-01 Death Factors(eg, FasL)
Oblimersen
Ad-p53
17AAG
Angiogenesis:SexaminibSU6668BevacizumabHuMV833CilengitideVitaxin 2CAIEndostatinAngiostatinThalidomideNeovastat2-Methoxy EstradiolSorafenibSunitinib VandetanibMotesanib diphosphate
Matrix Metalloproteinases:Batimastat BB-94Marimastat BB-2516BMS-275291BAY 12-9566COL3
GOOD NEWS!Breast Cancer Therapeutics: 2013
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• Hormone +:– Sorafanib + Letrozole
• Triple negative– Various agents + Avastin– High GPMB expressing – CDX-011 (celldex)– Parp inhibitors
• Others:– Abraxane + Afinitor
A Few Interesting Ongoing Studies
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• Bisphosphonates– Zoledronic Acid IV– Pamidronate IV
• Rank Ligand inhibitor- Denosumab sq
Importance of Bone Targeted Therapy
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• Focused treatment for symptom palliation
• Quadramet IV for more general pain control
Role of Radiation
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What Does It Mean In My Everyday Life?
•Common physical effects and things to watch
•Common psychosocial concerns
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Sharing Our Stories
Dikla Benzeevi
11-year Stage IV Breast Cancer Survivor and Advocate
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Question and Answer Session
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