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Advanced Breast Cancer: A Widening Spectrum of Options

Advanced Breast Cancer: A Widening Spectrum of Options

In this article, Drs. Briest and Stearns have provided a comprehensive review of the chemotherapeutic options for the treatment of advanced breast cancer. They also have provided a brief but cogent overview of nonchemotherapeutic approaches such as endocrine and targeted/biologic therapies, as well issues relevant to the management of advanced disease such as goals of therapy and factors that help determine the most appropriate treatment. All these topics are germane to clinical practice. The review is well organized and the summary tables of regimens commonly used in metastatic breast cancer will likely be a handy and useful resource for the practicing clinician.

Over the past 2 decades, there has been an expansion of chemotherapeutic options for the treatment of advanced breast cancer. Many of these therapies have significantly impacted our ability to palliate symptoms, control disease and even, in some cases, prolong survival. Whether population-based or single-institution studies[1,2] improvement in outcomes of patients diagnosed with metastatic breast cancer in the recent versus remote past can be attributed in part to these therapeutic advances. There remain, however, many unanswered questions regarding how to best use these chemotherapies.

Unaddressed Questions

Somewhat lacking in the review was an in-depth exploration of these questions: When considering single-agent vs combination chemotherapy, which approach is better, and why? When chemotherapies are used singly, is there an optimal way to sequence them? When combining therapies, what is the most rational way to combine them? Ultimately, can we further improve patient outcomes by simply knowing how to use currently available therapies optimally?

For many patients, the "demise of chemotherapy" is a much anticipated phenomenon, but it is unlikely that we can completely do away with chemotherapy any time soon. Many of the currently available biologic/targeted therapies work best in combination with chemotherapy. Take, for instance, trastuzumab (Herceptin) for patients with HER2-positive breast tumors. As a single agent it produces modest response rates[3] but has impressive response rates in combination with chemotherapy[4]—a classic example of synergy. The recently reported TrAstuzumab in Dual HER2 ER-positive Metastatic breast cancer (TAnDEM) trial showed a doubling in progression-free survival and improvement in overall response rates and time to progression when trastuzumab was combined with the endocrine therapy anastrozole.[5] However, these numbers were somewhat disappointing, especially in light of the high numbers seen with trastuzumab plus chemotherapy.

Optimizing Chemotherapy

So, if chemotherapy is here to stay for the next several decades, how can it be optimally used? Clearly, one way is to use it in a more "targeted" fashion. That is, as we learn more about the various subtypes of breast cancer and how biology dictates prognosis and response to therapy,[6,7] practicing clinicians can better select which chemotherapies are most appropriate for specific biologic subtypes. Of course, this will require knowing what predicts for response or resistance to specific chemotherapies. This is currently an area of active research.

The authors did not elaborate on how we might further elucidate this information. At the very least, the authors' insight or candid view of what critical milestones must be achieved or what pitfalls to watch out for, in my opinion, would have added a very interesting dimension to this review.

Predicting Individual Outcomes

Several times in their article, the authors mention that metastatic breast cancer is largely incurable. While this is true, it is also important to note that patients with metastasis have a wide range of survival, with some patients living for many years. Each patient diagnosed with breast cancer, more often than not, wants to know whether she is potentially curable and, if not, how much time she's "got left." The reality is that we do quite well at estimating averages but not so well at predicting these numbers for any given individual. We need to bridge this disconnect, the question is how? Perhaps a good place to start predicting "how an individual might perform" is in a truly individualized arena, the patient's quality of life.

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