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Case study 1

Case study 1. Richard Bell The Andrew Love Cancer Centre Geelong, Victoria, Australia. What is the National Spice of Hungary?. Curry Posh Ginger Jalape ñ o Paprika Basil. Where do you practice?. Western Europe Central/Eastern Europe Australia/New Zealand Latin America Asia

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Case study 1

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  1. Case study 1 Richard Bell The Andrew Love Cancer CentreGeelong, Victoria, Australia

  2. What is the National Spiceof Hungary? • Curry • Posh • Ginger • Jalapeño • Paprika • Basil

  3. Where do you practice? • Western Europe • Central/Eastern Europe • Australia/New Zealand • Latin America • Asia • Africa • North America

  4. Cristina’s story

  5. Cristina: breast cancer history • 1976 Aged 56, self-palpated right breast lump • biopsy – invasive ductal carcinoma • mastectomy and axillary clearance • pT2 [25mm] N0 M0 grade 2 • no systemic adjuvant treatment

  6. Cristina: breast cancer history • 1986 Aged 66, right thigh pain • lytic area femoral neck • right dynamic hip screw • biopsy – adenocarcinoma ER+/PR+ • 1986 Staging and treatment • lytic disease – right and left femur and right iliac bone • no visceral disease • treatment XRT and tamoxifen

  7. Cristina: visceral disease April 2002 • Now aged 82 • dyspnea, cough and right chestwall discomfort • ECOG PS=2–3 • She was referred to medical oncology with • a right pleural effusion • anorexia • substantial hepatomegaly ECOG PS = Eastern Cooperative Oncology Group performance status

  8. Cristina: visceral disease April 2002 • A CT scan revealed • pleural thickening • lung metastasis 5.0 x 2.0cm • multiple liver metastases (largest 2.8 x 2.0cm) • A bone scan showed degenerative joint disease only

  9. 2 1 3 Metastases confirmed by CT scan

  10. Elevated liver enzymesand hypercalcemia

  11. Treatment course: April–July 2002 • Tamoxifen discontinued • Commenced on an aromatase inhibitor • plus a bisphosphonate • After 12 weeks of the aromatase inhibitor • effusion worse • liver enzymes worse • alkaline phosphatase: 247  379U/L • gamma GT: 2429  3505U/L • repeat imaging: no change

  12. Female breast cancer in VictoriaIncidence and mortality by age group Source: Cancer Epidemiology Centre, 2005

  13. In this 82 year old women with metastatic breast cancer failing to respond to second-line hormonal therapy what would you do? • Chemotherapy would be the next treatment • I would institute another line of hormonal therapy • No active treatment: palliative care

  14. Which first-line chemotherapy would you choose? • Paclitaxel, weekly • Paclitaxel, 3-weekly • Docetaxel, weekly • Docetaxel, 3-weekly • Xeloda monotherapy • Xeloda + Taxotere (XT) • Gemcitabine + paclitaxel (GP) • Vinorelbine-based therapy • Anthracycline-based therapy

  15. July 2002: first-line Xeloda monotherapy • In July 2002 she began treatment with Xeloda 1000mg/m2 twice daily, days 1–14, q21d • reduced dose: age/liver dysfunction/ECOG PS=3 • After 4 cycles • felt better and appetite improved • liver enzymes improving • reduction in size of the liver metastasis

  16. After 15 cycles of Xeloda • Weight gain of 4kg • PS=0 • Liver enzymes normal • Liver edge just palpable

  17. Following a rapid response to Xeloda that was maintained for 11 months, what would you do now? • Maintain Xeloda 1000mg/m2 twice daily, days 1–14, q21d until progression or toxicity • Stop chemotherapy • Switch to another chemotherapy

  18. Continued management: April 2004 • Cristina remained on Xeloda 1000mg/m2 twice daily, days 1–14, q21d • April 2004: Now aged 84; had a great party • After 25 cycles of Xeloda she developed grade 2 hand-foot syndrome • Cristina continues to be well, no disease progression; PS = 0

  19. What would you do now? • Maintain Xeloda 1000mg/m2 twice daily, days 1–14, q21d • Reduce Xeloda dose to 750mg/m2 twice daily, days 1–14, q21d • Delay treatment until hand-foot syndrome resolved, then restart at a lower dose • Switch to another chemotherapy • Stop chemotherapy

  20. Xeloda continued at reduced dose • Treatment was delayed • Xeloda dose was reduced to 750mg/m2 twice daily, days 1–14, q21d, later q28d • April 2005: Cristina is now 85, another great party. She continues on Xeloda (cycle 36) • She is free from progression (PS = 0) • Mild hand-foot syndrome is her only side effect

  21. Case summary • After failure of two hormonal therapies this patient with extensive metastatic disease and liver dysfunction was treated with Xeloda monotherapy • rapid response • rapid symptom relief • excellent tolerability • The response has been durable and Cristina continues on maintenance Xeloda

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