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New Treatment Paradigms in Metastatic Breast Cancer
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Document Description
Breast cancer remains a significant cause of morbidity and mortal-
ity for women. In the United States, there are nearly 185,000 new cases
diagnosed annually and approximately 40,000 deaths (1). Since 1990,
there has been a steady reduction in mortality (2). This has largely been
attributed to earlier detection and improved therapy. A reduction in inci-
dence since 2003 has been attributed to the publication of the Women’s
Health Initiative Study, which demonstrated that hormone replacement
therapy (HRT) in postmenopausal women increases the risk of breast
cancer (3). Subsequent to that publication there has been a sharp decline
in the HRT use.
Clearly, the most significant advances in breast cancer therapy have
occurred in the adjuvant setting, resulting in a reduction in relapse. When
disease has spread beyond regional lymph nodes, it is almost always fatal.
Before 1990, chemotherapy for metastatic disease consisted essentially
of anthracyclines, antimetabolites, and alkylating agents. Over the past
20 years, a number of drugs have demonstrated benefit in the metastatic
setting, leading to the US Food and Drug Administration (FDA) ap-
proval of the three unique taxane formulations: an oral antimetabolite, a
nucleoside analog, and an epothilone. Furthermore, a vinca alkaloid and
a topisomerase I inhibitor have non-FDA–labeled indications. Addition-
ally, we have seen the emergence of growth factors and cardioprotective
agents such as dexrazoxane that have improved our ability to administer
these agents with a wider margin of safety. While the number of choices
has increased, the precise implementation of the choices remains more
of an art than a science.
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Content Preview
From the publishers of ONCOLOGY COAB
Clinical Oncology Advisory Board
New Treatment Paradigms
in Metastatic Breast Cancer
Ne
w T
r
eatment Paradigms in Metastatic Br
Supported by an educational grant from
east Cancer
Chau T. Dang, MD
Clifford A. Hudis, MD
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Cover_GC_V2_L.indd 1
11/5/2008 11:01:22 AM
Chemotherapy Treatment Paradigms in Metastatic Breast Cancer
?
New Treatment Paradigms in
Metastatic Breast Cancer
Edited by
Chau T. Dang, md
Clinical Assistant Physician
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
and
Clifford A. Hudis, md
Chief
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Publishers of
ONCOLOGY
Oncology News International
Cancer Management: A Multidisciplinary Approach
www.cancernetwork.com
Front_Matter_GC_V4.indd 1
11/13/2008 12:18:30 PM
COAB
Clinical Oncology Advisory Board
Note to the reader
The information in this book has been carefully reviewed for accuracy of dosage
and indications. Before prescribing any drug, however, the clinician should consult
the manufacturer’s current package labeling for accepted indications, absolute
dosage recommendations, and other information pertinent to the safe and effective
use of the product described. This is especially important when drugs are given
in combination or as an adjunct to other forms of therapy. Furthermore, some of
the medications described herein, as well as some of the indications mentioned,
may not have been approved by the U.S. Food and Drug administration at the
time of publication. This possibility should be borne in mind before prescribing
or recommending any drug or regimen.
Educational activities in the form of monographs, audio programs, supplements,
and other formats are sent to the readership of ONCOLOGY and Oncology News
International on a regular basis. All recipients of the journals can opt out of re-
ceiving them and accompanying educational activities at any time by contacting
our circulation department at CMPMedica, phone: (203) 662-6551 or by e-mail:
wdingle@cmp.com.
Copyright ©2008 by CME LLC. All rights reserved. This book is protected by copy-
right. No part of it may be reproduced in any manner or by any means, electronic
or mechanical, without the written permission of the publisher. Value: $19.95
Library of Congress Catalog Card Number 2008926820
ISBN 9781891483615
Cover image description: Breast cancer montage (clockwise from top): SEM of a
breast cancer cell superimposed over a woman holding her breasts; a photomi-
crograph of metastatic breast cancer in the lymph nodes, stained with immuno-
cytochemical for epithelial membrane antigen, mag. 400x; and a mammogram
showing breast cancer (arrow). Credit: Copyright © Scott Camazine / Phototake
– All rights reserved.
Publishers of
ONCOLOGY
Oncology News International
Cancer Management: A Multidisciplinary Approach
www.cancernetwork.com
Front_Matter_GC_V4.indd 2
11/13/2008 12:18:30 PM
?
Contents
Contributing Authors
iv
Continuing Medical Education
vi
Acknowledgments
ix
Preface
xi
Chapter 1: Chemotherapy Treatment Paradigms in
Metastatic Breast Cancer
1
by Steven M. Sugarman, MD
Chapter 2: Anti-HER2/neu Therapy for Metastatic
Breast Cancer
23
by Shanu Modi, MD
Chapter 3: Antiangiogenic Therapy for Metastatic
Breast Cancer
51
by Tiffany A. Traina, MD
Chapter 4: Hormonal Therapies for the Treatment of
Breast Cancer
67
by Shari Goldfarb, MD, and Maura Dickler, MD
Chapter 5: Supportive Therapy for Breast Cancer
91
by Diana E. Lake, MD
CME Post-Test
105
Index
109
To earn CME credit at no cost, please visit us online at
www.cancernetwork.com/cme
iii
Front_Matter_GC_V5.indd 3
11/18/2008 1:11:47 PM
?
Contributing Authors
Chau T. Dang, MD
Clinical Assistant Physician
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Clifford A. Hudis, MD
Chief
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Maura Dickler, MD
Assistant Attending Physician
Breast Cancer Medicine Service
Solid Tumor Service,
Department of Medicine
Memorial Sloan-Kettering Cancer Center
New York, New York
Shari Goldfarb, MD
Medical Oncology Fellow
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Diana E. Lake, MD
Clinical Associate Professor
Weill School of Medicine of Cornell University
Attending Physician
Memorial Sloan-Kettering Cancer Center
New York, New York
v
Front_Matter_GC_V4.indd 4
11/13/2008 12:18:31 PM
Contributing Authors
Shanu Modi, MD
Assistant Attending
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Steven M. Sugarman, MD
Assistant Chairman
Department of Medicine
Clinical Trials in the Regional Network
Memorial Sloan-Kettering Cancer Center
New York, New York
Tiffany A. Traina, MD
Assistant Attending Physician
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Front_Matter_GC_V5.indd 5
11/18/2008 1:21:23 PM
?
Continuing Medical Education
Monograph
Activity Release Date: December 1, 2008
Activity Expiration Date: December 1, 2009
About the Activity
The CME activity is based on the information learned from reading this
monograph, New Treatment Paradigms in Metastatic Breast Cancer. It was
developed from an identified educational need for information about
practical management issues in the practice of medical, surgical, and
radiation oncology.
This activity has been developed and approved under the direction of
the CME LLC.
Activity Learning Objectives
After reading New Treatment Paradigms in Metastatic Breast Cancer, partici-
pants should be able to:
• Incorporate all chemotherapeutic options (dealers choice) in
treating the patient with mBC.
• Effectively use the available Anti-HER2/neu therapies in the
metastatic setting.
• Assimilate the latest anti-angiogenesis trials.
• Demonstrate knowledge of all available Anti-Hormonals for mBC,
and how to effectively deal with their side-effect profiles.
• Utilize the best supportive care options into practice.
v
Front_Matter_GC_V4.indd 6
11/13/2008 12:18:31 PM
Continuing Medical Education
v
Target Audience
This activity targets physicians in the fields of oncology and hematology.
Accreditation
This activity has been planned and implemented in accordance with the
Essential Areas and policies of the Accreditation Council for Continu-
ing Medical Education through the joint sponsorship of CME LLC and
The Oncology Group. CME LLC is accredited by the ACCME to provide
continuing medical education for physicians.
Credit Designation
CME LLC designates this educational activity for a maximum of 3 AMA
PRA Category 1 Credits ™. Physicians should only claim credit commensu-
rate with the extent of their participation in the activity.
Physicians not licensed in the United States who participate in this CME
activity are eligible for AMA PRA Category 1 Credit(s)™.
Compliance Statement
This activity is an independent educational activity under the direction
of CME LLC. The activity was planned and implemented in accordance
with the Essential Areas and Policies of the ACCME, the Ethical Opin-
ions/Guidelines of the AMA, the FDA, the OIG, and the PhRMA Code
on Interactions with Healthcare Professionals, thus assuring the highest
degree of independence, fair balance, scientific rigor, and objectivity.
However, CME LLC, the Grantor, and CMPMedica shall in no way be
liable for the currency of information or for any errors, omissions, or
inaccuracies in the activity. Discussions concerning drugs, dosages, and
procedures may reflect the clinical experience of the author(s), or they
may be derived from the professional literature or other sources and may
suggest uses that are investigational in nature and not approved labeling
or indications. Activity participants are encouraged to refer to primary
references or to the full prescribing information resources. The opinions
and recommendations presented herein are those of the author(s) and
do not necessarily reflect the views of the provider or producer.
To earn CME credit at no cost, please visit us online at
www.cancernetwork.com/cme
Front_Matter_GC_V4.indd 7
11/13/2008 12:18:31 PM
v
Continuing Medical Education
Financial Disclosure
Dr. Dang has received research support from Genentech. Dr. Hudis has
served on the advisory board for Amgen, Bristol Myers-Squibb, Genen-
tech, Glaxo Smith-Kline, Novartis, Pfizer, Sanofi-Aventis; and has received
research support from AstraZeneca, Bristol Myers-Squibb, and Onyx
Pharmaceuticals. Dr. Dickler has served on the advisory board and has
acted as a consultant for Genentech, Novartis, Pfizer, and AstraZeneca.
Dr. Modi has served on the speaker’s bureau for Genentech; and has
received research funding from Genentech and Kosan Biosciences. Dr.
Sugarman has served on the speaker’s bureau for Lilly Pharmaceuticals
and Roche Pharmaceuticals. Dr. Traina has received an honorarium
and research support from Genentech. Drs. Goldfarb and Lake have no
financial relationships to disclose.
Copyright
Copyrights owned by CME LLC. Copyright ©2008.
Contact Information
We would like to hear your comments regarding this or other activities
provided by CME LLC. In addition, suggestions for future programming
are welcome. Contact us at:
Address: Director of Continuing Education
CME LLC
Harborside Financial Center
Plaza 3, Suite #806
Jersey City, NJ 07311
Phone: 888-618-5781
Supported by an educational grant from
Front_Matter_GC_V4.indd 8
11/13/2008 12:18:31 PM
?
Acknowledgments
This book was made possible thanks to the hard work of many people.
We are especially grateful to our many co-authors and colleagues who have
contributed to the individual chapters. Their dedication to advancing
the practice of breast cancer medicine is reflected in their high quality
contributions. We especially thank Paul Koren, Stuart Freeman, and other
colleagues at CME LLC and CMPMedica for giving us the opportunity
to write this book and for their patience and support. Finally, we would
like to thank all of our patients and their families who live and struggle
with breast cancer and who help us develop better therapies and more
treatment options by enrolling into clinical trials.
— Chau T. Dang, MD, and Clifford A. Hudis, MD
x
Front_Matter_GC_V4.indd 9
11/13/2008 12:18:31 PM
Clinical Oncology Advisory Board
New Treatment Paradigms
in Metastatic Breast Cancer
Ne
w T
r
eatment Paradigms in Metastatic Br
Supported by an educational grant from
east Cancer
Chau T. Dang, MD
Clifford A. Hudis, MD
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Cover_GC_V2_L.indd 1
11/5/2008 11:01:22 AM
Chemotherapy Treatment Paradigms in Metastatic Breast Cancer
?
New Treatment Paradigms in
Metastatic Breast Cancer
Edited by
Chau T. Dang, md
Clinical Assistant Physician
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
and
Clifford A. Hudis, md
Chief
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Publishers of
ONCOLOGY
Oncology News International
Cancer Management: A Multidisciplinary Approach
www.cancernetwork.com
Front_Matter_GC_V4.indd 1
11/13/2008 12:18:30 PM
COAB
Clinical Oncology Advisory Board
Note to the reader
The information in this book has been carefully reviewed for accuracy of dosage
and indications. Before prescribing any drug, however, the clinician should consult
the manufacturer’s current package labeling for accepted indications, absolute
dosage recommendations, and other information pertinent to the safe and effective
use of the product described. This is especially important when drugs are given
in combination or as an adjunct to other forms of therapy. Furthermore, some of
the medications described herein, as well as some of the indications mentioned,
may not have been approved by the U.S. Food and Drug administration at the
time of publication. This possibility should be borne in mind before prescribing
or recommending any drug or regimen.
Educational activities in the form of monographs, audio programs, supplements,
and other formats are sent to the readership of ONCOLOGY and Oncology News
International on a regular basis. All recipients of the journals can opt out of re-
ceiving them and accompanying educational activities at any time by contacting
our circulation department at CMPMedica, phone: (203) 662-6551 or by e-mail:
wdingle@cmp.com.
Copyright ©2008 by CME LLC. All rights reserved. This book is protected by copy-
right. No part of it may be reproduced in any manner or by any means, electronic
or mechanical, without the written permission of the publisher. Value: $19.95
Library of Congress Catalog Card Number 2008926820
ISBN 9781891483615
Cover image description: Breast cancer montage (clockwise from top): SEM of a
breast cancer cell superimposed over a woman holding her breasts; a photomi-
crograph of metastatic breast cancer in the lymph nodes, stained with immuno-
cytochemical for epithelial membrane antigen, mag. 400x; and a mammogram
showing breast cancer (arrow). Credit: Copyright © Scott Camazine / Phototake
– All rights reserved.
Publishers of
ONCOLOGY
Oncology News International
Cancer Management: A Multidisciplinary Approach
www.cancernetwork.com
Front_Matter_GC_V4.indd 2
11/13/2008 12:18:30 PM
?
Contents
Contributing Authors
iv
Continuing Medical Education
vi
Acknowledgments
ix
Preface
xi
Chapter 1: Chemotherapy Treatment Paradigms in
Metastatic Breast Cancer
1
by Steven M. Sugarman, MD
Chapter 2: Anti-HER2/neu Therapy for Metastatic
Breast Cancer
23
by Shanu Modi, MD
Chapter 3: Antiangiogenic Therapy for Metastatic
Breast Cancer
51
by Tiffany A. Traina, MD
Chapter 4: Hormonal Therapies for the Treatment of
Breast Cancer
67
by Shari Goldfarb, MD, and Maura Dickler, MD
Chapter 5: Supportive Therapy for Breast Cancer
91
by Diana E. Lake, MD
CME Post-Test
105
Index
109
To earn CME credit at no cost, please visit us online at
www.cancernetwork.com/cme
iii
Front_Matter_GC_V5.indd 3
11/18/2008 1:11:47 PM
?
Contributing Authors
Chau T. Dang, MD
Clinical Assistant Physician
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Clifford A. Hudis, MD
Chief
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Maura Dickler, MD
Assistant Attending Physician
Breast Cancer Medicine Service
Solid Tumor Service,
Department of Medicine
Memorial Sloan-Kettering Cancer Center
New York, New York
Shari Goldfarb, MD
Medical Oncology Fellow
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Diana E. Lake, MD
Clinical Associate Professor
Weill School of Medicine of Cornell University
Attending Physician
Memorial Sloan-Kettering Cancer Center
New York, New York
v
Front_Matter_GC_V4.indd 4
11/13/2008 12:18:31 PM
Contributing Authors
Shanu Modi, MD
Assistant Attending
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Steven M. Sugarman, MD
Assistant Chairman
Department of Medicine
Clinical Trials in the Regional Network
Memorial Sloan-Kettering Cancer Center
New York, New York
Tiffany A. Traina, MD
Assistant Attending Physician
Breast Cancer Medicine Service
Memorial Sloan-Kettering Cancer Center
New York, New York
Front_Matter_GC_V5.indd 5
11/18/2008 1:21:23 PM
?
Continuing Medical Education
Monograph
Activity Release Date: December 1, 2008
Activity Expiration Date: December 1, 2009
About the Activity
The CME activity is based on the information learned from reading this
monograph, New Treatment Paradigms in Metastatic Breast Cancer. It was
developed from an identified educational need for information about
practical management issues in the practice of medical, surgical, and
radiation oncology.
This activity has been developed and approved under the direction of
the CME LLC.
Activity Learning Objectives
After reading New Treatment Paradigms in Metastatic Breast Cancer, partici-
pants should be able to:
• Incorporate all chemotherapeutic options (dealers choice) in
treating the patient with mBC.
• Effectively use the available Anti-HER2/neu therapies in the
metastatic setting.
• Assimilate the latest anti-angiogenesis trials.
• Demonstrate knowledge of all available Anti-Hormonals for mBC,
and how to effectively deal with their side-effect profiles.
• Utilize the best supportive care options into practice.
v
Front_Matter_GC_V4.indd 6
11/13/2008 12:18:31 PM
Continuing Medical Education
v
Target Audience
This activity targets physicians in the fields of oncology and hematology.
Accreditation
This activity has been planned and implemented in accordance with the
Essential Areas and policies of the Accreditation Council for Continu-
ing Medical Education through the joint sponsorship of CME LLC and
The Oncology Group. CME LLC is accredited by the ACCME to provide
continuing medical education for physicians.
Credit Designation
CME LLC designates this educational activity for a maximum of 3 AMA
PRA Category 1 Credits ™. Physicians should only claim credit commensu-
rate with the extent of their participation in the activity.
Physicians not licensed in the United States who participate in this CME
activity are eligible for AMA PRA Category 1 Credit(s)™.
Compliance Statement
This activity is an independent educational activity under the direction
of CME LLC. The activity was planned and implemented in accordance
with the Essential Areas and Policies of the ACCME, the Ethical Opin-
ions/Guidelines of the AMA, the FDA, the OIG, and the PhRMA Code
on Interactions with Healthcare Professionals, thus assuring the highest
degree of independence, fair balance, scientific rigor, and objectivity.
However, CME LLC, the Grantor, and CMPMedica shall in no way be
liable for the currency of information or for any errors, omissions, or
inaccuracies in the activity. Discussions concerning drugs, dosages, and
procedures may reflect the clinical experience of the author(s), or they
may be derived from the professional literature or other sources and may
suggest uses that are investigational in nature and not approved labeling
or indications. Activity participants are encouraged to refer to primary
references or to the full prescribing information resources. The opinions
and recommendations presented herein are those of the author(s) and
do not necessarily reflect the views of the provider or producer.
To earn CME credit at no cost, please visit us online at
www.cancernetwork.com/cme
Front_Matter_GC_V4.indd 7
11/13/2008 12:18:31 PM
v
Continuing Medical Education
Financial Disclosure
Dr. Dang has received research support from Genentech. Dr. Hudis has
served on the advisory board for Amgen, Bristol Myers-Squibb, Genen-
tech, Glaxo Smith-Kline, Novartis, Pfizer, Sanofi-Aventis; and has received
research support from AstraZeneca, Bristol Myers-Squibb, and Onyx
Pharmaceuticals. Dr. Dickler has served on the advisory board and has
acted as a consultant for Genentech, Novartis, Pfizer, and AstraZeneca.
Dr. Modi has served on the speaker’s bureau for Genentech; and has
received research funding from Genentech and Kosan Biosciences. Dr.
Sugarman has served on the speaker’s bureau for Lilly Pharmaceuticals
and Roche Pharmaceuticals. Dr. Traina has received an honorarium
and research support from Genentech. Drs. Goldfarb and Lake have no
financial relationships to disclose.
Copyright
Copyrights owned by CME LLC. Copyright ©2008.
Contact Information
We would like to hear your comments regarding this or other activities
provided by CME LLC. In addition, suggestions for future programming
are welcome. Contact us at:
Address: Director of Continuing Education
CME LLC
Harborside Financial Center
Plaza 3, Suite #806
Jersey City, NJ 07311
Phone: 888-618-5781
Supported by an educational grant from
Front_Matter_GC_V4.indd 8
11/13/2008 12:18:31 PM
?
Acknowledgments
This book was made possible thanks to the hard work of many people.
We are especially grateful to our many co-authors and colleagues who have
contributed to the individual chapters. Their dedication to advancing
the practice of breast cancer medicine is reflected in their high quality
contributions. We especially thank Paul Koren, Stuart Freeman, and other
colleagues at CME LLC and CMPMedica for giving us the opportunity
to write this book and for their patience and support. Finally, we would
like to thank all of our patients and their families who live and struggle
with breast cancer and who help us develop better therapies and more
treatment options by enrolling into clinical trials.
— Chau T. Dang, MD, and Clifford A. Hudis, MD
x
Front_Matter_GC_V4.indd 9
11/13/2008 12:18:31 PM
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