EDITOR’S NOTE

As discussed in the Editor’s Note, we asked each of the 150 medical oncologists surveyed to describe a de-indentified case from their practice of a patient with metastatic breast cancer who had an extraordinarily impressive response to systemic therapy. We also asked the treating physician for a comment on the related educational message for this issue. The following are select examples of these cases.

I first saw this woman 25 years ago when she was 46. She presented with a primary breast tumor and widespread bone mets. We biopsied the breast and a bone met, and both proved to be the same adenocarcinoma. She had radiation therapy to the lumbar spine and a bilateral mastectomy. We then gave CMF chemotherapy, and after six cycles we started megestrol acetate. The woman is alive today without evidence of cancer 25 years later. She stayed on megestrol acetate forever. She must have been on that drug for 20 years, because no one knew what to do, and everyone was afraid to stop. We finally stopped about four or five years ago and she’s never had a recurrence.

COMMENT FROM TREATING PHYSICAN:

Normally, people who present with destructive lesions of the bone don’t live that long. It’s been very dramatic to watch this unfold.

This 45-year-old woman had extensive metastatic disease to the bones — the spine and basically the whole skeleton. She had severe pain from the boney involvement. She also had mets to the liver, and that caused her to have severe abdominal pain. The tumor was ER/PR-positive, HER2-negative. I treated her with doxorubicin and cyclophosphamide for four cycles, and then I started her on anastrozole. She has also been receiving zoledronic acid every month.

She had a complete response — complete disappearance of all of her tumor. There is no evidence of disease at this time more than two years later, and she continues on anastrozole and zoledronic acid.

COMMENT FROM TREATING PHYSICAN:

This woman had a bad cancer, and the fact that just hormonal therapy — after some chemotherapy — made her disease completely disappear, is very uncommon and not very likely. She was one of my exceptional cases.

This 83-year-old woman had neglected herself and came in with a large breast tumor and asymptomatic liver and lung metastases. She had a mastectomy and axillary node dissection that showed 14 positive lymph nodes. The tumor was strongly ER- and/or PR-positive and HER2-negative by FISH. She was brought in by her children. She was living alone and hadn’t seen a doctor. We put her on letrozole. That’s it; she is still receiving it now for almost two years. She’s had a near complete remission in her lung and liver metastases and has not had any recurrence on the chest wall.

COMMENT FROM TREATING PHYSICAN:

In someone whom we were treating for palliation, you want to use as benign a treatment as possible, because you’re not going to cure the patient, and you want their quality of life to be as optimal as possible. Here we have a drug like an aromatase inhibitor, which has minimal side effects. She responded very well to endocrine therapy. Visceral disease, unless it’s galloping along, is no contraindication to hormonal therapy in breast cancer.

This woman presented at age 52 with a very large breast mass that involved the chest wall and axillary lymph nodes clinically, and she also had extensive bone metastases. She was bedridden and extremely symptomatic and unable to walk because of her bone metastases. The breast mass was ER-positive.

She initially received six cycles of CAF followed by tamoxifen. Amazingly, this lady survived a total of 18 years. The breast mass and bone pain disappeared. She was on tamoxifen for approximately 12 years in remission before she had a relapse. She was ambulatory and went shopping and very much lived a normal life.

COMMENT FROM TREATING PHYSICAN:

This response was excellent in terms of symptom relief and duration of response. The bone metastases were completely painless and she was able to walk again. The duration of response was so long. For 18 years she had an excellent quality of life and was very functional.

A 65-year-old woman presented with a very large breast mass that had been ignored for a prolonged period of time. It was bleeding and fungating on the chest wall — really large — it had replaced the entire breast. She had a prior stroke from terrible valvular heart disease, which was causing her to throw clots. The stroke left her blind in one eye. She didn’t seek medical care until she began throwing clots from her heart disease. We biopsied the breast and it was infiltrating ductal adenocarcinoma, which was ER-positive and moderately differentiated. There was no evidence of metastatic disease, but the surgeon didn’t want to operate.

We decided to go forward with neoadjuvant doxorubicin/ cyclophosphamide. I started that with some trepidation, but after four cycles we decided to do a mastectomy and lymph node dissection because she had such a terrific response. At surgery you could see the tumor was necrosing but there was still viable tumor left and the lymph nodes were negative. She also decided to go forward with this heart surgery. It was very strange, but we ended up doing everything at the same time. She made it through the heart surgery easily, and the chemotherapy worked really well for the breast cancer.

After that I gave her four cycles of docetaxel, which seemed to consolidate everything, and now I have her on just anastrozole. The other thing that’s strange about her is that she has a myeloproliferative disorder, and I never had to worry about her platelets or her red count when I gave her chemo, because they were always really high. She’s a little old lady and I can’t believe she did this well.

COMMENT FROM TREATING PHYSICAN:

This older patient with multiple medical problems responded to chemotherapy terrifically, and it saved her life. This woman had a lot of reasons to die. She is hypercoagulable from her polycythemia and she had a problem with her heart, she’s stroking, and she had cancer that was ignored. It’s just unbelievable. These people are still treatable and sensitive to chemotherapy. Everything improved in this woman except her blindness from the stroke.

A 52-year-old woman with ER/PR-positive, node-positive tumor who previously received mastectomy, CMF and adjuvant tamoxifen for five years presented with chest pain and shortness of breath and was found to have bilateral pulmonary nodules and pleural effusions. I treated her first with letrozole and she had an excellent objective and symptomatic response. She returned to normal function. After five years, she progressed again and has now responded to fulvestrant for more than a year. Her performance status is excellent.

COMMENT FROM TREATING PHYSICAN:

This woman has done extremely well with metastatic disease for six years and has not required chemotherapy. Hormonal manipulation in some patients is an extremely effective palliative treatment and has allowed this woman to function extremely well with an almost normal quality of life.

A 32-year-old woman presented with inflammatory breast cancer metastatic to the lungs. She came in with shortness of breath and an obvious breast mass. The tumor was ERand/ or PR-positive and HER2 3+.

We treated her with doxorubicin/docetaxel, which resulted in a complete response in the breast and lungs. She then underwent mastectomy. After surgery we gave trastuzumab and tamoxifen. She is still free of cancer five years later and continues with trastuzumab every three weeks and tamoxifen as maintenance. She’s leading a normal life. She had toxicity with chemo early on, but now she’s doing great.

COMMENT FROM TREATING PHYSICAN:

Traditionally, in the “old days,” a patient like this would probably not go for so long free of disease. I think having a drug like trastuzumab really helped her and kept her disease at bay. These targeted drugs can change the natural history of the disease.

This 72-year-old woman had ignored a breast mass that basically destroyed her right breast and caused it to completely disappear. She also had extensive boney disease and liver mets. The tumor was ER-positive and HER-2 negative by FISH. She refused chemotherapy, so I prescribed anastrozole and she’s been on it for about three and a half years. Her bone lesions got better and her liver lesions went away. The breast mass went completely flat to the chest wall, which now looks totally normal.

COMMENT FROM TREATING PHYSICAN:

The fact that she had widely metastatic disease with a huge chest wall mass, and in spite of refusing chemotherapy or surgery, with simple hormonal manipulation, all of the disease virtually disappeared.

I met this woman when she was 38 years old after she had just been diagnosed with a relapse after adjuvant therapy. She had lymphadenopathy in the mediastinum, with nodes as large as five centimeters. She also had a couple of pulmonary nodules that were about two centimeters and was having a great deal of chest discomfort. The tumor was ERpositive, HER2-negative.

I sent her for radiation and put her on tamoxifen. She had a dramatic shrinkage of her adenopathy, and her pulmonary nodules have almost completely disappeared. She’s now been on tamoxifen for four years and feels very well in a continued remission.

COMMENT FROM TREATING PHYSICAN:

Under normal circumstances we would have expected this young lady to have died by now. The hormone sensitivity of her disease, in spite of her young age, is remarkable to me. When I first met her, I had a sinking feeling in my heart. She didn’t want to go on chemotherapy if she could avoid it, and it’s just amazing how well the tamoxifen has worked.

This 72-year-old woman had a prior mastectomy with no systemic therapy in the past. She presented with metastases to the bone, liver and lungs. She refused chemotherapy. I treated her with tamoxifen and she had a good response for two years. The tumor then progressed, and she received letrozole with no response. I then used fulvestrant and she had a near complete response that has lasted two years.

COMMENT FROM TREATING PHYSICAN:

Sometimes you cannot predict what will happen with hormonal therapies. In this case, the most impressive response occurred with the third agent used. This case demonstrates that it’s worth trying other hormonal therapies even if one doesn’t work.

This 62-year-old woman presented with headaches, double vision and failure to thrive. She had a four-centimeter mass in her breast that was ER/PR-positive, HER-2 negative. A metastatic evaluation revealed brain, lung, bone and liver metastases.

She did not want to undergo chemotherapy or radiotherapy. All she would accept was endocrine therapy, so I used anastrozole. She had an excellent response. Over the first month she stopped deteriorating and stabilized. Then she began to walk, eat and gain a little weight. By about two months she was ambulatory again. She was certainly not back to her old self but was on the way. This lasted about 18 months, and I now have her on fulvestrant. Scans and markers indicate she had an objective response to both anastrozole and fulvestrant.

COMMENT FROM TREATING PHYSICAN:

Despite her extremely poor prognostic factors upon presentation — the extensive metastases — that we would normally associate with poor endocrine response, she had an excellent endocrine response and very dramatic relief of symptoms and improved quality of life for more than two years.

This 65-year-old woman had neglected a breast mass for several years. She presented with difficulty walking, and was found to have spinal cord compression — she was completely paraplegic and also had lung and bone involvement with mets. She has a huge primary tumor and palpable axillary adenopathy. I treated her with radiation to the spine, trastuzumab, tamoxifen and then chemotherapy with gemcitabine and cyclophosphamide. The lung nodules pretty much disappeared and the breast mass shrank considerably — about 80 to 90 percent shrinkage. The axillary nodes disappeared. She’s now able to walk with a walker, and she’s regained about 50 percent of her motor strength. Her paraplegia has improved quite a bit.

COMMENT FROM TREATING PHYSICAN:

In my experience, when complete paraplegia is present from tumor spinal cord compression, probably 95 percent of the time the patient doesn’t recover enough nerve function to be able to walk. Essentially, it’s a life sentence of paraplegia. This woman has an excellent response to radiation, trastuzumab and chemo and was able to regain much of her strength, which is very, very uncommon when the patient has been paraplegic.

This 45-year-old woman was sent to me because she was having pain in the right upper quadrant of her abdomen and her internist did a CT scan that showed extensive liver metastases. I examined her and found a breast mass that was ER-negative and HER-2 positive breast cancer on biopsy. She had elevated liver function enzymes and bilirubin and metastatic disease to the brain, but she was asymptomatic. She also had lost about 20 pounds in the last month. She had all the criteria for a grave prognosis. We started her on trastuzumab and docetaxel for six cycles and the tumor responded beautifully. There was 90 percent response in her liver by CT scan criteria. She had gained back some of the weight she’d lost and she was 100 percent better than she was when she presented a year ago.

COMMENT FROM TREATING PHYSICAN:

When I started my career 10 years ago, such a patient would probably only live three to four months, given that most of the liver was involved with cancer and she had lost so much weight and had brain metastases. Typically, these patients do not live long. It has been a year and she continues to have an excellent quality of life on trastuzumab, and the tumor is responding beautifully. Now oncologists have more options than just chemotherapy — we have monoclonal antibody treatments like trastuzumab, which can really improve the quality of life and symptoms of women with breast cancer.