Ask the Experts - Therapy for Metastatic Breast Cancer With Abnormal...
Ask the Experts - Therapy for Metastatic Breast Cancer With Abnormal...
A 45-year-old woman with breast cancer developed extensive liver metastases after 6 months of adjuvant chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide. Her liver enzymes are markedly elevated, with transaminases in the 1000 IU/L range, and her bilirubin is 8 mg/dL. No bile duct obstructions were noted on imaging studies. What would you recommend for chemotherapy? I have started her on cyclophosphamide orally, but am reluctant to use methotrexate given her abnormal liver function tests.
Chemotherapy is usually warranted in a patient with rapidly progressive liver metastases and a short disease-free interval. However, the dose of many agents should be markedly reduced in the presence of an elevated bilirubin and no mechanical obstruction to relieve. Doxorubicin and other single agents have been used in this situation with acceptable toxicity.
If the bilirubin falls as the tumor responds, the dose can then be escalated. In particular, low-dose weekly paclitaxel or docetaxel can be considered with close monitoring for toxicity.
A 45-year-old woman with breast cancer developed extensive liver metastases after 6 months of adjuvant chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide. Her liver enzymes are markedly elevated, with transaminases in the 1000 IU/L range, and her bilirubin is 8 mg/dL. No bile duct obstructions were noted on imaging studies. What would you recommend for chemotherapy? I have started her on cyclophosphamide orally, but am reluctant to use methotrexate given her abnormal liver function tests.
Chemotherapy is usually warranted in a patient with rapidly progressive liver metastases and a short disease-free interval. However, the dose of many agents should be markedly reduced in the presence of an elevated bilirubin and no mechanical obstruction to relieve. Doxorubicin and other single agents have been used in this situation with acceptable toxicity.
If the bilirubin falls as the tumor responds, the dose can then be escalated. In particular, low-dose weekly paclitaxel or docetaxel can be considered with close monitoring for toxicity.