BC with multiple bony metastases.

[youmeetus]

My mother was diagnosed with Breast cancer in July 2005.  She underwent MRM, her histopathology report confirmed infiltrating duct carcinoma, grade II, NBR Score 7, 10/18 nodes with metastatic deposit. She is post menopausal with ER Score 170(moderately positive) PR Score (Moderately Positive) and negative for HER-2/NEU gene amplification, with ratio of total HER-2 signals/total CEP 17 signals (B/C)=1.16 (Fish Technique) She received 8 cycles of chemotherapy, 2 T (Taxotere) AC cycles (her normal LVEF 72% fell to 50%) therefore, chemoplan was changed to 4 cycles of CMF followed by increased dose of 2T (Taxotere). she received radiation (27 frs) to the left chest flap and simultaneously was put on TAMOXIFEN from Feb. 2006 onwards. she was on follow up during which remarkable endometrial thickening was detected therefore, she was switched to AROMASIN in August 2007.  From September 2007 she started complaining pain in her right knee and back. On thorough examination, the whole body bone scan and PET CT scan confirmed multiple bone metastases. Involving ribs, thoraco lumbar vertebrae with partially collapsed d8 vertebra (no cord compression, neurological deficit, stability is maintained) right knee showing large metastasis involving distal femur. She was prescribed with monthly Zolodronic Acid and received palliative radiation to dorsal spine and right femur. She was also switched over to new hormonal treatment called FASLODEX.  Till dated she has received 6 shots of faslodex and 7 shots of Zolodronic Acid.  Last month April 2008 after her initial diagnosis of bony metastases she underwent follow up PET SCAN which revealed progressive disease involving entire spine, sacrum, multiple foci in pelvic bones, right proximal femur and multiple foci throughout left femur, left knee, and head of right humerus, sternum and multiple bilateral ribs, with no visceral involvement. She again underwent palliative radiation for right humerus girdle and entire left femur. She has shown regression in areas where she had previously received palliative radiation to the sites in October 2007.

What should be the future course of treatment? please guide.

[HeinrikMD]

Hi,

The disease at this point is generally incurable. Hence, problems are dealt with as they come.

At the present time, disease is largely limited to bone. Since she has endocrine responsive, the treatment with Faslodex is appropriate. The Zometa also improves the odds of getting bone complications, with radiation reserved for more problematic sites in bone.

IF the disease involves other organs like liver or lung, the option of chemotherapy would probably be offered.  

[youmeetus]

Thank you Heinrik,

she has been switched to a newer hormonal treatment i.e. Femara since new bones have been affected in the past six months while she was on monthly Faslodex and zolodronic acid. my concern is how potent or effficacious is Femara as compared to Faslodex? and why she is not showing good response to the hormonal treatments although she is ER/PR+. lastly how effective is the chemotherapy in case of bony mets? i was given to understand that people with bony mets have an extended life but i have my doubts now. please guide.

Thanks.

[HeinrikMD]

Hi,

You are correct that the hormonal responsiveness is a function of the ER and the PR assay. The greater role for these medications is actually in the setting of early breast cancer, in which these medications are able to provide more cures.

In the metastatic setting, the goals of therapy are largely to control the tempo of disease (cures are within the realm of possibility, but these are rare). Hence, even the ER PR positive patients would have disease that may only be controlled over a matter of months, the progression is an expected outcome. How soon the progression comes would of course vary, for some this may only be over 8 to 12 weeks, for others it may be several months.

The Femara would be an option for as long she is already menopause. There is no direct comparison between Faslodex and Femara. Both were compared with the former standard which was Tamoxifen, and both have been found superior.