POC Breast 1 | 2007 - Systemic Therapy for Metastatic Disease

Patterns of Care in Patterns of Care in Medical OncologyMedical Oncology

Systemic Therapy for Metastatic Disease

When you use ovarian suppression for a When you use ovarian suppression for a premenopausal patient with metastatic premenopausal patient with metastatic

breast cancer, which regimen do breast cancer, which regimen do you generally recommend? you generally recommend?

Monthly leuprolide or monthly goserelin

76% 60%

Leuprolide or goserelin every three months

24% 40%

Clinical investigators Practicing oncologists

Which first-line endocrine therapy would Which first-line endocrine therapy would you generally use on progression after 4 you generally use on progression after 4

years of adjuvant anastrozole? years of adjuvant anastrozole?

Tamoxifen 45% 19%

Fulvestrant 39% 45%

Exemestane 14% 19%

Letrozole 0% 12%

Other 2% 5%


What percent of your patients with What percent of your patients with metastatic breast cancer would prefer to metastatic breast cancer would prefer to receive a monthly injection of fulvestrant receive a monthly injection of fulvestrant

rather than a daily oral endocrine agent such rather than a daily oral endocrine agent such as an aromatase inhibitor or tamoxifen? as an aromatase inhibitor or tamoxifen?

Mean 20% 28%


One acceptable clinical option for patients One acceptable clinical option for patients with ER-positive tumors who develop with ER-positive tumors who develop

progressive metastatic disease on an AI is progressive metastatic disease on an AI is to continue the AI and add fulvestrant.to continue the AI and add fulvestrant.

Agree 10% 21%

In between 16% 33%

Disagree 74% 46%


When using fulvestrant in the When using fulvestrant in the metastatic setting, do you generally metastatic setting, do you generally

use a loading dose?use a loading dose?

2005 2006 2007

Clinical investigators (CI)

Percent answering yes 53% 67% 76%

Practicing oncologists (PO)


A 60-year-old woman was diagnosed 3 years earlier with ER-A 60-year-old woman was diagnosed 3 years earlier with ER-positive, PR-positive, positive, PR-positive, HER2-positiveHER2-positive breast cancer and breast cancer and

received adjuvant received adjuvant AC followed by tamoxifenAC followed by tamoxifen, which she has , which she has now received for 3 years. She did now received for 3 years. She did notnot receive adjuvant receive adjuvant

trastuzumab. She now presents with moderately symptomatic trastuzumab. She now presents with moderately symptomatic bone metastases and no other sites of disease on staging. bone metastases and no other sites of disease on staging.

Which therapy would you recommend to this patient? Which therapy would you recommend to this patient?

Endocrine therapy + trastuzumab 66% 58%

Endocrine therapy alone 24% 17%

Chemotherapy + trastuzumab 10% 11%

Endocrine therapy + chemotherapy+ trastuzumab

0% 11%

Endocrine therapy + chemotherapy 0% 3%


If endocrine therapy alone or in combination If endocrine therapy alone or in combination was chosen above, which endocrine therapy was chosen above, which endocrine therapy

would you recommend? would you recommend?

Anastrozole 64% 70%

Letrozole 18% 8%

Exemestane 11% 14%

Fulvestrant 7% 8%


A 60-year-old A 60-year-old asymptomaticasymptomatic woman presents with de novo woman presents with de novo metastatic disease to bone and liver. A breast biopsy shows metastatic disease to bone and liver. A breast biopsy shows an ER-positive, PR-positive, HER2-positive tumor, and a liver an ER-positive, PR-positive, HER2-positive tumor, and a liver biopsy confirms metastatic disease. Which is your most likely biopsy confirms metastatic disease. Which is your most likely

initial treatment strategy?initial treatment strategy?

Chemotherapy + trastuzumab 37% 37%

Endocrine therapy + trastuzumab 31% 31%

Endocrine therapy alone 28% 12%

Endocrine therapy + chemotherapy + trastuzumab

4% 20%


Have you used nanoparticle Have you used nanoparticle or or nabnab paclitaxel? paclitaxel?

2005 2007


Percent answering yes 73% 98%



If yes, in how many patients?If yes, in how many patients?

2005 2007


Mean 4 17


Mean 2 12

In your opinion, how would you compare the In your opinion, how would you compare the resolution of Grade III/IV neuropathy resolution of Grade III/IV neuropathy

experienced by patients receiving experienced by patients receiving nabnab paclitaxel versus paclitaxel? paclitaxel versus paclitaxel?

Patients tend to experience resolution of neuropathy faster on nab paclitaxel

37% 55%

No difference 61% 42%

Patients tend to experience resolution of neuropathy faster on paclitaxel

2% 3%


Approximately what Approximately what percentpercent of your of your patients have experienced an allergic patients have experienced an allergic

reaction when using the following reaction when using the following taxanes for breast cancer?taxanes for breast cancer?

Paclitaxel

Mean 6% 11%

Docetaxel

Mean 4% 9%


Approximately Approximately how manyhow many of the patients in of the patients in your practice in the last 3 years, if any, have your practice in the last 3 years, if any, have

had a significant infusion reaction when had a significant infusion reaction when using the following taxanes?using the following taxanes?

Paclitaxel

Mean 7 9

Docetaxel

Mean 3 6


A 53-year-old woman with metastatic breast cancer, A 53-year-old woman with metastatic breast cancer, bone-only metastases and minimal symptoms will bone-only metastases and minimal symptoms will

receive one of the following therapies. Please receive one of the following therapies. Please indicate the premedications you would use for each indicate the premedications you would use for each

one of these regimens:one of these regimens:

Antihistamines Dexamethasone Other* None

Paclitaxel 93% 91% 98% 94% 31% 30% 1% 4%

Docetaxel 34% 53% 94% 93% 10% 18% 6% 6%

Nab paclitaxel

2% 22% 1% 30% 6% 17% 93% 52%


* Primarily antiemetics

What percent of your patients with breast What percent of your patients with breast cancer do you think would prefer not having cancer do you think would prefer not having

to receive premedication for taxanes?to receive premedication for taxanes?

Mean 76% 48%


What percent of your patients with What percent of your patients with breast cancer do you think would breast cancer do you think would

consider it an important advantage to consider it an important advantage to have a shorter infusion time?have a shorter infusion time?

Mean 70% 61%

Approximately what percent of patients with Approximately what percent of patients with metastatic breast cancer who receive taxane metastatic breast cancer who receive taxane premedication with dexamethasone develop premedication with dexamethasone develop

the following symptoms? (Mean)the following symptoms? (Mean)

At least one night of insomnia 38% 36%

Weight gain to the point that it is bothersome

22% 19%

Agitation to the point that it is bothersome

16% 17%

Exacerbation or new onset of diabetes 9% 18%


If cost and reimbursement for If cost and reimbursement for nabnab paclitaxel paclitaxel were the same as for paclitaxel, with what were the same as for paclitaxel, with what

percent of patients to whom you would percent of patients to whom you would currently recommend paclitaxel for currently recommend paclitaxel for

metastatic breast cancer would you use metastatic breast cancer would you use nabnab paclitaxel instead?paclitaxel instead?

Mean 80% 64%


A 60-year-old woman presents with de novo metastatic ER-A 60-year-old woman presents with de novo metastatic ER-negative, PR-negative, HER2-negative breast cancer. She has negative, PR-negative, HER2-negative breast cancer. She has

bone and lung metastases and is mildly symptomatic. bone and lung metastases and is mildly symptomatic. Her Her health insurance will cover 100% of any therapy you health insurance will cover 100% of any therapy you

prescribe.prescribe. You have decided to use a taxane as part of your You have decided to use a taxane as part of your treatment strategy. Which taxane, if any, would you most treatment strategy. Which taxane, if any, would you most

likely recommend for this patient? likely recommend for this patient?

Nab paclitaxel 55% 39%

Paclitaxel 39% 23%

Docetaxel 6% 38%


A 60-year-old woman was diagnosed 3 years earlier with ER-A 60-year-old woman was diagnosed 3 years earlier with ER-negative, PR-negative, HER2-negative breast cancer and negative, PR-negative, HER2-negative breast cancer and received adjuvant AC. She now presents with moderately received adjuvant AC. She now presents with moderately

symptomatic bone metastases and no other sites of disease symptomatic bone metastases and no other sites of disease on staging. How would you compare the following on staging. How would you compare the following

agents/regimens for this particular case? agents/regimens for this particular case? Your preferred Your preferred docetaxel-based regimen (Doc) versus your preferred docetaxel-based regimen (Doc) versus your preferred nab nab

paclitaxel-based regimen (paclitaxel-based regimen (NabNab):):

Efficacy

2006 2007


Doc is significantly more efficacious 0% 0%

Doc is somewhat more efficacious 2% 4%

Both are similar in efficacy 91% 43%

Nab is somewhat more efficacious 7% 45%

Nab is significantly more efficacious 0% 8%



agents/regimens for this particular case? agents/regimens for this particular case? Your preferred Your preferred docetaxel-based regimen (Doc) versus your preferred docetaxel-based regimen (Doc) versus your preferred nabnab


Efficacy

2006 2007


Doc is significantly more efficacious 1% 2%

Doc is somewhat more efficacious 12% 12%


Nab is somewhat more efficacious 18% 27%

Nab is significantly more efficacious 0% 2%





Safety and tolerability

2006 2007


Doc has significantly better safety and tolerability 0% 4%

Doc has somewhat better safety and tolerability 2% 0%

Both are similar in safety and tolerability 32% 18%

Nab has somewhat better safety and tolerability 59% 62%

Nab has significantly better safety and tolerability 7% 16%






2006 2007


Doc has significantly better safety and tolerability 3% 3%

Doc has somewhat better safety and tolerability 7% 9%

Both are similar in safety and tolerability 39% 35%

Nab has somewhat better safety and tolerability 44% 46%

Nab has significantly better safety and tolerability 7% 7%

Have you used bevacizumab for metastatic Have you used bevacizumab for metastatic breast cancer off protocol?breast cancer off protocol?

2005 2006 2007





Have you used endocrine therapy in Have you used endocrine therapy in combination with bevacizumab?combination with bevacizumab?



For patients with ER-negative, For patients with ER-negative, PR-negative, HER2-negative tumors, PR-negative, HER2-negative tumors, the following bevacizumab therapy the following bevacizumab therapy

combinations are potentially acceptable combinations are potentially acceptable in the first-line setting.in the first-line setting.

Capecitabine + bevacizumabCapecitabine + bevacizumab

2006 2007


Agree 42% 52%

In between 24% 24%

Disagree 34% 24%



Capecitabine + bevacizumabCapecitabine + bevacizumab

2006 2007


Agree 41% 49%

In between 32% 32%

Disagree 27% 19%



Capecitabine + paclitaxel + bevacizumabCapecitabine + paclitaxel + bevacizumab

2006 2007


Agree 29% 22%

In between 27% 25%

Disagree 44% 53%



Capecitabine + paclitaxel + bevacizumabCapecitabine + paclitaxel + bevacizumab

2006 2007


Agree 38% 37%

In between 41% 39%

Disagree 21% 24%



Carboplatin + paclitaxel + bevacizumabCarboplatin + paclitaxel + bevacizumab

2006 2007


Agree 34% 39%

In between 32% 28%

Disagree 34% 33%



Carboplatin + paclitaxel + bevacizumabCarboplatin + paclitaxel + bevacizumab

2006 2007


Agree 48% 49%

In between 35% 32%

Disagree 17% 19%

For a patient who presents with asymptomatic For a patient who presents with asymptomatic metastatic disease and no prior systemic therapy, metastatic disease and no prior systemic therapy,

how would you compare capecitabine to how would you compare capecitabine to capecitabine + bevacizumab?capecitabine + bevacizumab?

Efficacy

Capecitabine is significantly more efficacious

0% 2%

Capecitabine is somewhat more efficacious

4% 2%


Capecitabine + bevacizumab is somewhat more efficacious

66% 62%

Capecitabine + bevacizumab is significantly more efficacious

6% 6%


For a patient who presents with asymptomatic For a patient who presents with asymptomatic metastatic disease and no prior systemic therapy, metastatic disease and no prior systemic therapy,

how would you compare capecitabine to how would you compare capecitabine to capecitabine + bevacizumab?capecitabine + bevacizumab?


Capecitabine has significantly better safety and tolerability

8% 10%

Capecitabine has somewhat better safety and tolerability

74% 41%

Both are similar in safety and tolerability

14% 44%

Capecitabine + bevacizumab has somewhat better safety and tolerability

4% 4%

Capecitabine + bevacizumab has significantly better safety and tolerability

0% 1%


A 60-year-old woman was diagnosed 3 years earlier A 60-year-old woman was diagnosed 3 years earlier with ER-negative, PR-negative, HER2-negative with ER-negative, PR-negative, HER2-negative breast cancer and received AC. She now has breast cancer and received AC. She now has

moderately symptomatic bone metastases and no moderately symptomatic bone metastases and no other sites of disease on staging. Which therapy other sites of disease on staging. Which therapy

would you recommend to this patient?would you recommend to this patient?

Assuming cost and reimbursement were an issue

Chemotherapy alone 45% 54%

Chemotherapy + bevacizumab 55% 46%


A 60-year-old woman was diagnosed 3 years earlier A 60-year-old woman was diagnosed 3 years earlier with ER-negative, PR-negative, HER2-negative with ER-negative, PR-negative, HER2-negative breast cancer and received AC. She now has breast cancer and received AC. She now has

moderately symptomatic bone metastases and no moderately symptomatic bone metastases and no other sites of disease on staging. Which therapy other sites of disease on staging. Which therapy

would you recommend to this patient?would you recommend to this patient?

Assuming cost and reimbursement were not an issue

Chemotherapy alone 20% 38%

Chemotherapy + bevacizumab 80% 62%


A 60-year-old woman received AC for an ER-negative, A 60-year-old woman received AC for an ER-negative, PR-negative, HER2-negative tumor. One year later, she is PR-negative, HER2-negative tumor. One year later, she is

diagnosed with asymptomatic bone metastases and two small diagnosed with asymptomatic bone metastases and two small pulmonary nodules. Cost and reimbursement issues aside, pulmonary nodules. Cost and reimbursement issues aside, which therapy is likely to provide the best therapeutic ratio?which therapy is likely to provide the best therapeutic ratio?

A taxane + bevacizumab 74% 61%

Capecitabine 18% 11%

Capecitabine + bevacizumab 6% 13%

A taxane 2% 15%


If the patient receives capecitabine and shows a If the patient receives capecitabine and shows a response but the disease progresses after 9 months response but the disease progresses after 9 months

of therapy, which therapy would then provide the of therapy, which therapy would then provide the best therapeutic ratio?best therapeutic ratio?


A taxane 22% 25%

Other 4% 6%


A 60-year-old woman received AC for an ER-negative, PR-A 60-year-old woman received AC for an ER-negative, PR-negative, HER2-negative tumor. negative, HER2-negative tumor. Three years laterThree years later, she is , she is diagnosed with diagnosed with very symptomaticvery symptomatic bone metastases and bone metastases and

multiple hepatic and pulmonary nodulesmultiple hepatic and pulmonary nodules. Cost and . Cost and reimbursement issues aside, which therapy is likely to provide reimbursement issues aside, which therapy is likely to provide

the best therapeutic ratio? the best therapeutic ratio?


A taxane + capecitabine 6% 15%

A taxane 2% 11%

Capecitabine 2% 7%

Other 6% 10%


Same patient: Same patient: One year laterOne year later, she is diagnosed with , she is diagnosed with asymptomaticasymptomatic bone metastases and bone metastases and 2 small pulmonary 2 small pulmonary

nodulesnodules and receives docetaxel. She shows a response, but and receives docetaxel. She shows a response, but the disease progresses after a total of 9 months of therapy. the disease progresses after a total of 9 months of therapy.

Cost and reimbursement issues aside, which therapy is likely Cost and reimbursement issues aside, which therapy is likely to provide the best therapeutic ratio?to provide the best therapeutic ratio?

Capecitabine 59% 30%

Viborelbine or capecitabine+ bevacizumab

35% 29%

Nab paclitaxel + bevacizumab 4% 13%

Paclitaxel + bevacizumab 2% 15%

Other 0% 13%


Have you used the metronomic regimen of Have you used the metronomic regimen of bevacizumab, cyclophosphamide and bevacizumab, cyclophosphamide and

methotrexate presented by Harold Burstein at methotrexate presented by Harold Burstein at the 2005 San Antonio meeting?the 2005 San Antonio meeting?

2006 2007





Patients with metastatic disease experiencing Patients with metastatic disease experiencing prolonged useful responses to bevacizumab with prolonged useful responses to bevacizumab with

chemotherapy should be presented with the option chemotherapy should be presented with the option of continuing bevacizumab and switching to of continuing bevacizumab and switching to

another chemotherapy at the time of progression.another chemotherapy at the time of progression.

Agree 29% 47%

In between 22% 35%

Disagree 49% 18%


Are you familiar with the Are you familiar with the RIBBON trials 1 and 2?RIBBON trials 1 and 2?



If yes, have you enrolled If yes, have you enrolled patients in these trials?patients in these trials?


Taking into consideration the Taking into consideration the safety, tolerability,safety, tolerability, cost and reimbursementcost and reimbursement of the following metastatic of the following metastatic breast cancer treatments, how much of a benefit in breast cancer treatments, how much of a benefit in progression-free survival would you require clinical progression-free survival would you require clinical trials to demonstrate trials to demonstrate for you to generally prefer that for you to generally prefer that therapytherapy? Assume that the available trial data are not ? Assume that the available trial data are not

mature enough to evaluate overall survival.mature enough to evaluate overall survival.

To generally prefer nab paclitaxel over standard paclitaxel

Mean number of months 3.6 4.6


Taking into consideration the Taking into consideration the safety, tolerability,safety, tolerability, cost and reimbursementcost and reimbursement of the following metastatic of the following metastatic breast cancer treatments, how much of a benefit in breast cancer treatments, how much of a benefit in progression-free survivalprogression-free survival would you require clinical would you require clinical trials to demonstrate trials to demonstrate for you to generally prefer that for you to generally prefer that therapytherapy? Assume that the available trial data are not ? Assume that the available trial data are not


To generally prefer bevacizumab + paclitaxel over paclitaxel alone



Taking into consideration the Taking into consideration the safety, tolerability,safety, tolerability, cost and reimbursementcost and reimbursement of the following metastatic of the following metastatic breast cancer treatments, how much of a benefit in breast cancer treatments, how much of a benefit in progression-free survivalprogression-free survival would you require clinical would you require clinical trials to demonstrate trials to demonstrate for you to generally prefer that for you to generally prefer that therapytherapy? Assume that the available trial data are not ? Assume that the available trial data are not


To generally prefer trastuzumab + an aromatase inhibitorover an aromatase inhibitor alone



Health & Medicine

POC Breast 1 | 2007 - Systemic Therapy for Metastatic Disease