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LET’S TALK ABOUT METASTATIC BREAST CANCER: Answers to Your Most Pressing Medical and

]. LET’S TALK ABOUT METASTATIC BREAST CANCER: Answers to Your Most Pressing Medical and Psychosocial Concerns. Mission. communities to increase the quality and quantity of life for women diagnosed with breast cancer ages 40 and under.

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LET’S TALK ABOUT METASTATIC BREAST CANCER: Answers to Your Most Pressing Medical and

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  1. ] LET’S TALK ABOUT METASTATIC BREAST CANCER: Answers to Your Most Pressing Medical and Psychosocial Concerns

  2. Mission communities to increase the quality and quantity of life for women diagnosed with breast cancer ages 40 and under. Young Survival Coalition (YSC) is the premier international organization dedicated to the critical issues unique to young women and breast cancer. YSC works with survivors, caregivers, and the medical, research, advocacy and legislative

  3. Tonight’s Speakers Generosa Grana, MD Professorof Medicine, CMSRU Director, Cooper CancerInstitute & 11-Year Stage IV Survivor DiklaBenzeevi

  4. Metastatic Breast Cancer • Presentation • Sites of Disease • Prognosis • Treatment Options • Hormonal Therapy • Chemotherapy • Biologic Therapy • Radiation • Supportive Measures • Bisphosphonates, etc.

  5. Important Elements Defining goals Communicating with oncology team & with family Early use of palliative care / supportive care resources Use of psychosocial support services

  6. Metastatic Disease Prognosis Determining Factors: • Sites of recurrence • Skin, nodes>pleura, bone >lung, liver • Brain > meninges • Time from diagnosis to recurrence • Type of tumor (ER, HER2/neu) • Significant improvements with available new drugs (chemo, hormonals, biologics)

  7. Current selection of therapy Based on sites of disease – urgency Previous therapy (prior anthracyclines, taxanes, type of hormonal therapy) Pre-existing toxicity (neuropathy, cardiomyopathy, other) Menopausal status ER / PR status HER2/neu status Patient goals (weekly vs. Q 3 week, oral vs. IV, hair loss vs. not, etc) (compliance)

  8. Goals of Treatment Palliation of symptoms Improve survival Tumor response

  9. Systemic Treatment Options Metastatic Disease ER &/Or PR + Non-life threatening Disease -- Hormone Therapy ER- / PR- Her 2 neu – -- Chemotherapy Single Agent Combination Her 2 – neu + Er- / Pr- -- Her2 targeted + Chemo Er &/or Pr + -- Hormone Rx Hormone + Herceptin alone

  10. Management of MetastaticBreastCancer Diagnosis of metastatic breast cancer Determination of sites and extent of disease Assessment of HER2, HR status, disease-free interval, age, and menopausal status No life-threatening disease, hormone responsive Hormone unresponsive or life-threatening disease First-line hormonal therapy First-line chemotherapy No response Progression Response Second-line chemotherapy Progression Second-line hormonal therapy No response Progression Response Third-line chemotherapy Progression Supportive care No response Third-line hormonal therapy

  11. Debates Chemotherapy vs. Hormone Therapy Single Agent vs. Combination Therapy Sequence of agents When to integrate hormonal agents if ER+ Sequence in HER2/neu + disease Approach to triple negative disease Approach to BRCA1/2 + disease

  12. What Are TheOptionsFollowingTamoxifen? Tamoxifen First treatment Second treatment Nonsteroidal AI Fulvestrant Fulvestrant Steroidal AI Nonsteroidal AI Third treatment Fourth treatment Steroidal AI Nonsteroidal AI Steroidal AI Other options for subsequent therapy: progesterone agents, high-dose estrogen, AI + everolimus, clinical trial

  13. Hormonal TherapyOptionsforMetastaticDisease Postmenopausal • Antiestrogens (SERMS) • Aromatase Inhibitors • SERDS (Faslodex) • Progestins • Androgens • Estrogen Premenopausal • Antiestrogens (SERMS) • Tamoxifen • Toremifene • Ovarian Suppression • Antiestrogens + os

  14. Recent Additions Chemotherapy: Halaven (erebulin) Others in testing HER2/neu based therapy: Pertuzumab Kadcyla Neratinib – in testing Hormonal therapy: Faslodex Exemestane + Afinitor Novel compounds Parp inhibitors Vaccines Others

  15. Future Choices • Genetic profile of tumor • Caris, individual institutional research programs • Genetic profile of host – metabolizing pathways??? • Better understanding of pathways and relationship between pathways

  16. GOOD NEWS! Breast Cancer Therapeutics: 2013 5-AzacytidineDecitabineFazarabineDepsipeptide Paclitaxel DocetaxelDolastatin IxabepiloneBenzoylphenylurea Angiogenesis:SexaminibSU6668BevacizumabHuMV833CilengitideVitaxin 2CAIEndostatinAngiostatinThalidomideNeovastat2-Methoxy EstradiolSorafenibSunitinib VandetanibMotesanib diphosphate OxaliplatinGemcitabineIrofulven Cilengitide Flavopiridol ErlotinibSU6668SexaminibGefitinibTrastuzumabLapatinib 17AAG WNT Cells Bortezomib ECM CC49LMB-9Mab CO17-1A Growth Factors(eg, TGFa) TipifarnibBMS-214662 Ad-p53 Hormones(eg, Bombesin)(eg, Estrogen) Oblimersen Survival Factors(eg, IGF1) Matrix Metalloproteinases:Batimastat BB-94Marimastat BB-2516BMS-275291BAY 12-9566COL3 Bryostatin-1 EverolimusTemsirolimus IL-4IL-12IFN UCN-01 Death Factors(eg, FasL) Cytokines(eg, ILs, IFNs) Bortezomib

  17. A Few Interesting Ongoing Studies • Hormone +: • Sorafanib + Letrozole • Triple negative • Various agents + Avastin • High GPMB expressing – CDX-011 (celldex) • Parp inhibitors • Others: • Abraxane + Afinitor

  18. Importance of BoneTargeted Therapy • Bisphosphonates • Zoledronic Acid IV • Pamidronate IV • Rank Ligand inhibitor- Denosumab sq

  19. Role of Radiation Focused treatment for symptom palliation Quadramet IV for more general pain control

  20. What Does It Mean In My Everyday Life? Common physical effects and things to watch Common psychosocial concerns

  21. Sharing Our Stories Dikla Benzeevi 11-year Stage IV Breast Cancer Survivor and Advocate

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