bony mets

my mother is 66 years old and had 2 primary breast cancers dxed in 1979 and 1987 treated with surgery and radiation.  Lymph nodes were negative.  In the past 6 months, she was having hip pain and workup revealed bony mets to both femurs, pelvis, sacrum, several places in her spine and in the skull (at the clivus). The tumors were ER/PR strongly positive. She has no visceral mets.  The cancer in 1979 had neg receptors and the lesion in 1987 was not tested. For the past several years she was on HRT for menopause, which of course she has stopped. She is in excellent health otherwise. 2 days ago she had her femur stabilized surgically by an orthopedic oncologist.  Do you think she should start treatment 1st with hormonal therapy alone or would you recommend combing with chemo?  If you recommend hormonal therapy alone 1st, would you start with Femara, Arimidex or Faslodex? The research that I have done seems to favor Femara.  Would you ever recommend using Arimidex/femara at the same time?--there are studies currently investigating this but I am unaware of the preliminary findings.  How about using celebrex at the same time?--again there is research ongoing currently--I figure that it could only help b/c it inhibits aromatase plus it may help with pain.  What dose would of celebrex would you use if so? She has received her 1st dose of Zometa. She is is excellent health otherwise, works out, eats right and has no other signif medical problems, so I want her to get the best. I am a physician, so please feel free to speak in technical terms.  What would you do if this was your mom?

[CCF-RN,MSN-JS]

Dear melly143, The goal of treatment of metastatic breast cancer is to control the disease and symptoms of the disease for as long as possible. Hormonal therapy can be very effective in doing this.  The three medications that you have listed have the same basic mechanism of action - being aromatase inhibitors.  The aromatase inhibitor that was studied in comparison to tamoxifen (an anti-estrogen) as first line treatment of advanced breast cancer was Arimidex, and has been subsequently approved for first line therapy in advanced breast cancer in post-menopausal women. The other 2 medications have been approved as second-line therapy.  

Combination therapy would more likely use drugs with different mechanisms of action, so using a combination of 2 different aromatase inhibitors would not be a likely scenario.  Celebrex (celecoxib) is a COX-2 inhibitor. Celebrex has been studied in the setting of metastatic breast cancer in combination with Aromasin (exemestane, another aromatase inhibitor) to see if the combination of these two drugs shows benefit.  Early studies have shown promise however, more study is needed to determine if this will be demonstrated in larger groups of patients.

Another option in treatment of advanced disease might be Herceptin ( a monoclonal antibody which targets the Her-2 neu receptor on breast cancer cells), if her tumor has tested positive for Her-2 neu.

The decision regarding use of chemotherapy would be made keeping in mind the goals of treatment, her overall health, past treatment and quality of life issues.  A thorough discussion between your mother and the oncologist regarding the risks vs. benefit of treatment in her individual situation needs to happen in order for her to make that decision.