Hello doctor, The patient is a 36-year-old female. She is a metastatic breast cancer patient. The diagnosis was made three years ago. Metastasis found this year through FDG PET CT scan. The primary treatment was for breast lumpectomy, followed by chemotherapy (3 FEC+3 Docetaxel), and radiation therapy. For MBC at liver took Trastuzumab plus Leuprolide 3.75 ( eight cycles) and Letrozole 2.5mg. There was a progression to bilateral oophorectomy plus DJ stenting at the urethra. Also, Trastuzumab plus Letrozole. After progression on Trastuzumab and Fulvestrant. Is the present treatment plan as per guidelines as per ESMO or ASCO? If not, then what does the guideline say? The patient feels pain in the abdomen region which worsens at night. As per the urologist, there is no gynecological or urological problem as very recently the DJ stent was replaced with new one. What is the solution?
Hello. It looks like she is having progressive metastatic breast cancer triple positive (ER +, Her 2 +ve). She received chemotherapy, hormonal, and target therapy (Trastuzumab). She also underwent BCS, oophorectomy, plus radiotherapy. Despite all this treatment. she progressed twice. Before I give some suggestions I need to know about her general condition (walking, eating well, recent weight loss, pain control, any chronic illness)? Any family history of breast cancer? If her performance status is good and she is tolerating all the medicines well, she must take more treatment. There are now few options left. That is to add Pertuzumab, Lapatinib or TDM-1. But all of these medicines are very expensive and now at this stage, if there is diffuse metastasis these medicines will not have a curative role but only a palliative role and may add some benefit only. Another option is to start Eribulin injection (chemotherapy) which can be given after progression from Taxane and Anthracycline chemotherapy or to start some other drugs as palliative chemotherapy. The abdomen pain she is experienced may be related to liver metastasis. She has received treatment as per guidelines till now except (Pertuzumab/TDM 1) which are very expensive and few people afford it. Unfortunately, as per the reports (attachment removed to protect patient identity), it is an advanced malignancy. Now the goal of the treatment is just palliation. Her performance status looks 2 (ECOG). The goal of the treatment should be to control her pain, to maintain intake (nutrition) and output (bowel bladder habits). Provide her psychological support and family support. She should also visit her oncologist for follow up if she is not willing for chemotherapy. At least hormonal treatment and Bisphosphonates are recommended and will be well tolerated (after consultation with a primary oncologist). Lapatinib at this stage may even cause more toxicity than benefit (diarrhea, vomiting, hand-foot syndrome, cardiac toxicity). For more information consult a medical oncologist online -->