[Debbie L.]

Hi Alex,

Did you have Herceptin with the paclitaxel?

This seems like a good time for a second opinion, preferably at an NCI-designated comprehensive cancer center if you're in the US ( http://cancercenters.cancer.gov/canc...ers-list2.html . There is no specific sequence of drugs. Although it seems like each onc has their own favorites, it's essentially a matter of using the tools in the toolbox as slowly as possible, weighing toxicities (side effects) against efficacy.

Just because response to a taxane was disappointing doesn't necessarily mean that the cancer won't respond to other chemos and/or anti-HER2 agents.

Here (copy/pasted below) is a list of chemos plus Herceptin (or Tykerb) from the NCCN guidelines. I found these at "advancedbc.org" which also has two pages of "treatments in common use", listed with links to more info about each one. Look to the sidebar on the left for those pages at this site: http://www.advancedbc.org/

Preferred Chemotherapy Regimens for Recurrent or Metastatic Breast Cancer (pages BINV-M 1-6)

• “The NCCN Clinical Practice Guidelines in Oncology™ – the recognized standard of care in oncology – are the most comprehensive and most frequently updated clinical practice guidelines available in any area of Medicine. Covering 97 percent of all patients with cancer and updated on a continual basis, the NCCN Guidelines are developed through an explicit review of the evidence integrated with expert medical judgment by multidisciplinary panels from NCCN Member Institutions.”
• NCCN uses different levels of evidence in its practice guidelines, and indicates that all of these recommendations are considered Category 2A unless otherwise noted. Category 2A means complete consensus among the NCCN breast cancer panel members, based on lower level evidence (than Category 1), including clinical experience, that the recommendation is appropriate.
• Preferred single agents are:
  • Anthracyclines: Adriamycin (doxorubicin), Ellence (epirubicin), Doxil (pegylated liposomal doxorubicin)
  • Taxanes: Taxol (paclitaxel), Taxotere (docetaxel), Abraxane (albumin-bound paclitaxel)
  • Xeloda (capecitabine)
  • Navelbine (vinorelbine)
  • Gemzar (gemcitabine)
  • Eribulin (eribulin mesylate)

“There is no compelling evidence that combination regimens are superior to sequential single agents.” -- NCCN Guidelines (v.1.2012)

• Other active options:
  • Platinums: Cisplatin and Carboplatin
  • Cytoxan (cyclophoshamide)
  • Oral etoposide (VP-16 and others)
  • Vinblastine
  • Continuous infusion fluoruoricil (5-FU)
  • Ixempra (ixabepilone)
  • Novantrone (mitoxantrone)
• Preferred: Avastin (bevacizumab) with Taxol (paclitaxel)
• In metastatic breast cancer patients with HER2+ disease:
  • Preferred first-line chemotherapy combinations with Herceptin (trastuzumab):
    • Taxol (paclitaxel) with or without carboplatin
    • Taxotere (docetaxel)
    • Navelbine (vinorelbine)
    • Xeloda (capecitabine)
  • Preferred second-line combinations for Herceptin-exposed patients:
  • Tykerb (lapatinib) with Xeloda (capecitabine)
  • Herceptin (trastuzumab) with other first-line preferred chemotherapy agents
  • Herceptin (trastuzumab) with Tykerb (lapatinib) without chemotherapy
• Preferred chemotherapy combinations:
  • CAF/FAC (cyclophosphamide, doxorubicin,fluorouracil) Cytoxan, Adriamycin and 5-FU
  • FEC (fluorouracil, epirubicin, cyclophoshamide) 5-FU, Ellence and Cytoxan
  • AC (doxorubicin, cyclophosphamide) Adriamycin and Cytoxan
  • EC (epirubicin, cyclophosphamide) Ellence and Cytoxan
  • AT (doxorubicin, docetaxel) Adriamycin and Taxotere
  • CMF (cyclophosphamide, methotrexate, flourouricil) Cytoxan, Methotrexate, and 5-FU
  • TC (docetaxel, capecitabine) Taxotere and Xeloda
  • GT (gemcitabine, taxol) Gemzar and Taxol
• See NCCN Guidelines --pages BINV-M 2-6-- for specific dosing and scheduling for all of the above treatments, as well as for references on the research upon which these guidelines are based.
• The NCCN Guidelines conclude with the following statement:
• “The selection, dosing and administration of anti-cancer agents and the management of associated toxicities are complex. Modifications of drug dose and schedule and initiation of supportive care interventions are often necessary because of expected toxicities and because of individual patient variability, prior treatment, and comorbidity. The optimal delivery of anti-cancer agents therefore requires a health care delivery team experiences in the use of anti-cancer agents and the management of associated toxicities in patients with cancer. “