tykerb and brain mets

[Lauriesh]

Hi everyone,

I am trying to convince my onc to let me add in tykerb along with the herceptin I am on. I am stage 4, with mets to liver. I am having rfa for the one remaining liver lesion this Fri, and I am NED everywhere else.

Are there any studies that show tykerb helps prevent brain mets? I don't think there are, but I know that I don't keep up with the latest research, as some of you do. That is the reason that I am asking him to let me add in the tykerb.

Are there any stage 4er's who are NED taking this combo?

Thanks for your help,

Laurie

[Jackie07]

Laurie,

The abstract below seems to be what you are looking for. You can ask your doctor/clinic if they can find the full article for you. Below the abstract are two postings made by Joan in another thread about the NCCN Guideline which includes entries on the combination of Tykerb (Lapatinib) and Herceptin (Trastuzumab).

Clin Cancer Res. (http://javascript<b></b>:AL_get(this,%20'jour',%20'Clin%20Cancer%20Res.'); ) 2011 Jan 19. [Epub ahead of print]
New strategies in HER2-overexpressing breast cancer: Many combinations of targeted drugs available.
Abramson V (http://www.ncbi.nlm.nih.gov/pubmed?term=%22Abramson%20V%22%5BAuthor%5D), Arteaga CL (http://www.ncbi.nlm.nih.gov/pubmed?term=%22Arteaga%20CL%22%5BAuthor%5D).
Hematology/Oncology, Vanderbilt University.
Abstract
The anti-HER2 drugs trastuzumab and lapatinib are increasingly changing the natural history of early and metastatic HER2-overexpressing breast cancer. Many other agents targeted against the HER2 signaling network are in clinical development. These are or will soon be combined with the currently approved anti-HER2 therapies. We review herein recent data in support of the early use of combinations of agents targeted to the HER2 network as the most rational approach against this subtype of breast cancer. We propose the optimal combination or combinations of anti-HER2 agents delivered early in the natural history of HER2+ breast cancer should close to eliminate acquired drug resistance, shorten the duration of therapy, and potentially dispense with the need of concurrent chemotherapy.

Joan has just posted in another thread (To treat or not to treat) about the NCCN guideline which includes the combination of Tykerb (Lapatinib) and Herceptin (Trastuzumab). I think there are clinical trials somewhere testing the effect of the combination. But from what I know, Tykerb is a smaller molecule that can cross the blood-brain barrier.

I'd like to add that the point about the NCCN guidelines is that many doctors and insurance companies follow them. So, if you're being told that Herceptin is not for you, it might be based on just those guidelines. Two breast cancer medical oncologist from Sloan-Kettering are on the board of the NCCN breast cancer guidelines. On the other hand, some oncologists, even at major cancer facilities, bend the rules, and as Weety pointed out, ASCO has its own guidelines.

Another NCCN guideline problem is using Herceptin and Tykerb together even if a metastatic survivor progresses on Herceptin. Survivors on the board have expressed concern that their oncologists will not prescribe both drugs toegther, even though they do not mention the guidelines. Tykerb has been approved by the FDA for use only with Xeloda. But Dr. Eric Winer of Dana Farber/Harvard Medical School was touting online the superior results of these two drugs in combination, at a recap of metastatic breast cancer from the December San Antonio Breast Cancer Symposium. Yet doctors -- and insurance companies -- will still deny patients. Last week I wrote an e-mail to Dr. Carlson of Stanford University, who is on the NCCN breast cancer guidelines board pointing this out to him, since the NCCN's annual meeting is coming up soon. Dr. Winer is also on that board, as well as the two oncologists from Sloan-Kettering.

From my own personal experience at a major world renown cancer institute in NYC, I was advised in 2004 by a breast oncologist of no minor standing after I finished my treatments for stage 2b breast cancer at a local NYC hospital, that follow up should comprise only blood work and tumor markers, but no scans because of the stage of the cancer. I left the consultation thinking that with a 2.5 cm tumor that was HER2+, ER-/PR- and seven positive lymph nodes that hell would freeze over before I wasn't scanned. My local oncologist agreed to scan me routinely and three years later a 9mm tumor was found in my lung. After that I asked for an annual brain MRI, and the second one showed a 2.6 cm tumor. The brain surgeon at Sloan-Kettering was "teasing" me by saying that she'd heard I'd found my own brain tumor, because I did not yet have symptoms.

My sense about cancer is that if oncologists practically have "to kill" us with chemo to kill cancer, what does that tell us about cancer?

xxxxxxxx

Just want to give a clarification or update. It seems that herceptin and tykerb (trastuzumab and lapatinib) given together without chemotherapy are listed as a treatment for metastatic breast cancer. It's on page 56 of the guidelines (capecitabine is Xeloda):

NCCN Guidelines for PatientsTM: Breast Cancer

Discussion Version 2010

Preferred Chemotherapy Regimens in Combination with Trastuzumab
(HER2-Positive Metastatic Disease)

• Paclitaxel with or without carboplatin
• Docetaxel
• Vinorelbine
• Capecitabine

Preferred Regimens for HER2-Positive Tumors Already Treated with Trastuzumab (HER2-Positive Metastatic Disease)

Lapatinib and capecitabine
Trastuzumab with different chemotherapy drug than was used before
Trastuzumab and capecitabine
Trastuzumab and lapatinib (with no other chemotherapy)


This is a relief to know, as several women had complained about not being able to get both together. I believe it was Sheila whose insurance company initially would not pay for Herceptin and Tykerb in combination, but only for Tykerb and Xeloda (capecitabine). After much pavement pounding with the insurance company, doctors, and the drug companies, I believe the insurance company finally agreed. Another woman mentioned more recently that her oncologist did not want to prescribe the two drugs together and was being cautious.

Joan

[Jackie07]

Laurie,

I just saw the treatment history of Trish. She had the combo of Tykerb and Herceptin last May. Below is her treatment history:

May 2004 (R) mastctomy 30mm bre gr3 infiltrating ductal ca 16/18nodes+
er (2+) pr (3+) HER2 (3+)
June 2004 6 cycles chemo (FEC), Oct 40 rads (5x/6wks), Tamoxofen
May 2006 oopherectomy, Arimedex
Dec 2006 liver mets largest 9cm
Jan 2007 Herceptin,
March 2007 Taxol + Herceptin
Jan 2008 Herceptin alone
April 2008 Multiple bone mets,Zometa
July 2008 Herceptin + Gemcitabine
Aug 2008 Herc+Navelbine +Vinoralbin
Oct 2008 Herc+Carboplatin+Taxol
Dec 2009 Tykerb+Xeloda
Feb 2010 Herceptin + trial drug
May 2010 Herceptin+Tykerb
August2010 Tykerb+Abraxane
Sept 2010 Abraxane
Dec2010 Abraxane+Tykerb+Herceptin

[Trish]

Laurie I'm on Herceptin and Tykerb but I'm in Australia so our battle is with government bodies rather than insurance companies. The govt will only fund Tykerb or Herceptin not both together, and they will only fund Tykerb with Xeloda. I have managed so far not to pay for Tykerb because I had some left over from when it was prescribed with Xeloda, Glaxo Smith Kline gave me some free of charge and because my dose is lower (3 tabs i.e. 750mg/day)because I am hypersensitive to it. Soon I will have to pay for it but I am hoping there will be some cost sharing deal. The combination of the two and Abraxane are still working for me and when I finish with Abraxane I hope to have Tykerb, Herceptin and an anti hormonal.
Good luck convincing the insurance companies because I have had great success with the combination. All the best,
Trish

[Lauriesh]

Dear Jackie and Trish,

Thanks for the info. I will see my onc on Wed. and I will find out if he will give me Tykerb. He said that he wanted some time to look at the research, so hopefully he will decide to give it to me based on what he finds. I will definitely bring in the info you gave me to help persuade him.

thanks again,

Laurie

[Ceesun]

Currently on herceptin and tykerb together for the past 14 months with good results----shrinkage and "holding things in check" per the tumor board Jan 2011. Ceesun