Navelbine + Gemcitabine

[alex1]

Onco suggested Navelbine + Gemcitabine . As per onco disease not responding to aggressive treatment being given .What are other options at this stage ? Has anybody got bone metastates cleared in PET scan after chemo ?


_________________________________________________
Age 38 years
17 Feb 2010 – Mammography – Mass in right breast suspicious of malignancy
19 Feb 2010 – FNA from right breast – Duct carcinoma cells seen
04 Mar 2010 – Right radical modified mastectomy – tumor 3X3X2, LN1/19 +ve
15 Mar 2010 – Hormone receptor – ER negative, PR negative, c erb B2 –
positive score3
25 Mar 2010 – Detection of HER-2/neu by FISH - positive
1 Apr 2010 – Chemotherapy Started – 3 CEF + 4 Docetaxel + Herceptin (3wkly X 17)
30 May 2011 – Course of Herceptin completed
9 Aug 2011 – CT Scan – focal lesion 3.2X2.9cm in segment IV of liver
10 Aug 2011 – PET-CT Scan – solitary hepatic metastasis, precaval LN suspicious mets
15 Aug 2011 – Oral chemotherapy started – Tykerb 250, Xeloda 500
28 Feb 2012 – PET-CT Scan –hepatic metastasis,lymphatic
metastasis,skeletal metastasis
03 Mar 2012 - I.V. 3 weekly chemo started PacliALL (Paclitaxel ) given
05 May 2012 - PET CT Scan " Hypermetabolic hepatic , lymphatic and osseous metastates . Paclitaxel ineffective.

[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/cancer_centers/cancer-centers-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 (http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf) (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 (http://www.nccn.org/professionals/physician_gls/PDF/breast.pdf) --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. “

[Jackie07]

Stephanie had had 27 rounds of Taxol, Navelbine, and Herceptin before her liver attained the NED status. Below is her treatment history:


Found suspicious lump 9/2000
Lumpectomy, then node dissection and port placement
Stage IIB, Grade 3, ER & PR -
Adriamycin 12 weekly, taxotere 4 rounds
36 rads
3 mos after rads liver full of tumors, Stage IV Jan 2002
Weekly Taxol, Navelbine, Herceptin for 27 rounds to NED!
2003 & 2004 no active disease - 3 weekly Herceptin + Zometa
Jan 2005 two mets to brain - Gamma Knife on Jan 18
All clear until suspicious spot on Jan 2006 brain MRI & PET
Brain surgery on Feb 9, 2006 - no cancer, all radiation necrosis
Continue as NED while on Herceptin & quarterly Zometa
Fall-2006 - off Zometa - watching one small brain spot (scar?)
2007 - spot/scar in brain stable - finished anticoagulation therapy for clot along my port-a-catheter - 3 angioplasties to unblock vena cava
2008 - Nov. 2009 Brain and body still NED! Port removed and scans in Dec.
Dec 2008 - stop Herceptin - STILL NED in late 2011 - on wing & prayer
Vaccine Trial at U of W begun in Oct. of 2011