Monday, December 26, 2016

Quest for the Cure Breast Cancer Treatment - Case Study Lisa

The Patient of the Future

left breast cancer
In August 2000, Lisa Bridges, age 43, was diagnosed with cancer in her left breast. The tumor was small and was located in the lower inner quadrant. She was treated with a modified radical mastectomy because three nodes from the left axilla contained metastases and there was extranodal extension into the perinodal fat with focal intravascular invasion. The tumor was ER2, PR2, and HER21 with a 31 score.

The following month, she consulted a medical oncologist in Evansville, IN who recommended that she receive adjuvant chemotherapy to be followed by radiation therapy to the peripheral lymphatics and the chest wall. An adjuvant therapy program was begun that month that consisted of the undeservedly popular AC 34, followed by consolidation with Taxol as a single agent 34. Fortunately, Adriamycin was administered by continuous infusion and the adjuvant program was completed without incident.

On a routine a follow-up examination in August 2002, a mass was discovered in Lisa’s left upper lung. Lung tissue obtained by needle biopsy showed a poorly differentiated adenocarcinoma consistent with metastatic high-grade breast cancer. Several other sites were suspicious for metastases, including the hilum of the right lung and the 11th and 12th thoracic and 5th lumbar vertebrae. Lisa was started on weekly Herceptin (trastuzumab), a monoclonal antibody that blocks the HER2 receptor. Meanwhile, she visited MDA, Memorial Sloan-Kettering, Vanderbilt, and the University of Indiana. Each facility turned her down because they did not have an ongoing treatment protocol for which she was eligible.

In January 2003, Navelbine (vinoralbine), a vinca alkaloid that blocks dividing cells was added to her therapeutic regimen and Lisa first consulted Blumenschein later that month. His initial move was to refer her to Dr. Dan Meyer, a thoracic surgeon in Dallas, who was willing to attempt surgical removal of her lung metastasis. One week later, he operated and got her lung into a complete remission.

However, a major question was, how would resection of the lung lesion benefit a patient who had other sites of cancer spread? So Blumenschein used TAC 36 for induction and FUMEP 32 for consolidation adjuvant chemotherapy. Herceptin, which had been discontinued preoperatively, was restarted weekly with Navelbine, but had to be stopped after four doses because of declining cardiac function. Testing in the summer of 2003 showed blastic healing of the thoracic vertebrae and radiation oncologists proceeded with radiation therapy consolidation.

By September 2003, Lisa’s hilar lymph nodes were becoming a problem and radiation therapy was called into action once again.  Unfortunately, this resulted in radiation pneumonitis for which she had to receive steroid therapy. In July 2004, Lisa’s pleura-based lesion returned. By November 2004, it had increased by 70% and a pleural nodule was surgically removed. Although this nodule showed no evidence of cancer, the surgery was repeated in January 2005 and cancer was present.

In November 2005, the lung lesion was again growing and Herceptin therapy was resumed. This time it was given with Abraxane, a formulation of paclitaxel bound to albumin. Seven months later, Lisa’s chest scans had cleared and Abraxane was discontinued. Herceptin was continued every week until October 2006, when it again had to be stopped because of decreasing cardiac function. At that time, she was considered to be in complete remission. Herceptin was restarted when Lisa’s cardiac function improved but had to be discontinued again in November 2007 when her cardiac function deteriorated again. At this time, restaging studies showed NED. Herceptin was resumed from January 2008 through July 2008 at which time the staging studies continued to show NED.

Lisa is going to require aggressive follow-up. By my dated criteria she may not be cured, but could be classified as in Herceptin-maintained complete remission in Abraxane complete remission or in Abraxane complete remission maintained by Herceptin. In this sense, Lisa Bridges is the patient of the future who never completely eradicates cancer clones but may control them with intermittent or continuous therapy. There is the possibility that the pattern of behavior demonstrated by Lisa’s cancer will direct us toward a new strategy of maintenance therapy built around drugs like Herceptin that have specific targets.

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