Meet Eric Winer, MD - Our October Expert

Treatment for Metastatic (Advanced) Breast Cancer

Eric Winer, MD, received his undergraduate and medical degrees from Yale University. He trained in internal medicine and served as chief resident at Yale-New Haven Hospital. Dr. Winer was a hematology-oncology fellow at Duke University Medical Center from 1987-89 and then remained on the faculty at Duke until 1997.

In 1997, he moved to Dana-Farber Cancer Institute and Brigham and Women's Hospital in Boston. Currently, Dr. Winer is Director of the Breast Oncology Program at the Dana-Farber Cancer Institute. He is Associate Professor of Medicine at Harvard Medical School. Dr. Winer is also the co-chair of the Cancer and Leukemia Group B Breast Committee. Dr. Winer has participated in numerous practice guidelines panels and is the chair of the ASCO Technology Assessment Panel on the use of aromatase inhibitors in the adjuvant setting.

Dr. Winer serves as an editorial board member of the Journal of Clinical Oncology, Breast Cancer Research, Breast Cancer Research and Treatment, and Clinical Breast Cancer. He is a prolific contributor to the oncology scientific and clinical literature, contributing original research articles, editorials and textbook chapters.

Question Four:

I am now 41, but diagnosed with stage 4 breast cancer with mets to the bone at age 38. I am ER, PR positive. I was on chemo for a year and my disease has been stable for about a year off chemo. I have surgically induced menopause. I have been on Arimidex and Aromasin and well as Aredia once a month. There was slight progression of disease while on Arimidex and Aromasin. Is Femara a good choice to try next? My doctor has also given me the choice of Lupron or Tamoxifen.

I would appreciate your insight. Thank you for your time. Joy

Dr. Winer's Response:

Arimidex (Anastrozole) and Aromasin (Exemestane) are both aromatase inhibitors. Femara (Letrozole) is also an aromatase inhibitor. These drugs are only effective in postmenopausal women, or in premenopausal women who are made postmenopausal by either undergoing an oophorectomy or taking drugs like Lupron. They work by dramatically decreasing the levels of estrogen in a woman's body.

If Arimidex and Aromasin have stopped working, it is unlikely that Femara will be effective. I would move on to another therapy. There are other hormonal treatments including Tamoxifen, Fulvestrant (which is a pure antiestrogen), and Megace (a progestin). Of course, there are also many chemotherapy agents and drugs like Herceptin (If a woman's tumor is HER2 positive). You do not need or want Lupron if your ovaries have been removed. Lupron works by surpressing ovarian function, and if your ovaries have already been removed, it will not have any effect.

Question Three:

I think one thing that is difficult with having mets is that you know the probable outcome and you know the general survival time but you also hope to be the person that lives for years and years. So on the one hand you want/need to have a normal life and continue to work (whether for the health insurance or to help the family get back financially) but on the other hand you want to know whether you should just quit and spend as much time as possible with family and doing other fulfilling things you always wanted to do.

Do you ever help a patient decide or recommend that it is time to stop working? If so, when and how? Do you base it on liver function or other tests? Do you ever tell them, this is the time to stop because you are getting to the point where physically they are too ill to do them?

Dr. Winer's Response:

Metastatic breast cancer is incurable, but as you suggest, there are women who live with the illness for many, many years. Some women live for a decade or longer, and there are new treatments on the horizon that should help some women live even longer.

I believe that women with metastatic breast cancer, and people with similar problems, need to live each day, week, and month as they come. For many of us, however, that is a hard way to live. Many women with metastatic breast cancer struggle with the issues that you describe. On the one hand, you want to live life as normally as possible, and, on the other hand, you want to make sure you do all the things that are most important to you. In general, I tend to think that women who try to maintain a normal life tend to do the best from an adjustment standpoint, but this does not mean that a woman should bury her head in the sand and pretend that the cancer does not exist. Women often find it helpful to talk about these issues with doctors, nurses, social workers, and other health professionals. Friends and family can be helpful of course, but the conversations are often even more difficult and always more complicated.

There usually is a point in time when I advise against further active treatment. That point in time varies from person to person, but if I think treatment is going to cause more harm than good, I advise against it. I rarely tell women that they have to stop working unless its clear to me tat work is just leading to exhaustion. That said, I think open discussions about work and other lifestyle choices should be part of the conversation that a doctor and patient regularly have. I do my best to be frank about how long I think someone is likely to live, but I never know for sure and I always talk about a range, not a specific amount of time. These conversations are tough both for patients and doctors. In truth, not all women with breast cancer want to have these conversations, and not all doctors engage in them.

Question Two:

Do you feel that er/pr positive, premenopausal breast cancer patients, regardless of the stage of their disease, should receive ovarian suppression and an aromatase inhibitor? Thank you.

Dr. Winer's Response:

In premenopausal women with early stage (stage I and II) breast cancer, the standard adjuvant treatment remains tamoxifen. Outside of a clinical trial, some doctors will add ovarian suppression to tamoxifen, and there is some evidence to support this approach. The evidence to support ovarian suppression is strongest in women who have not also received chemotherapy.

Outside of a clinical trial, I would generally recommend against an aromatase inhibitor with ovarian suppression in the vast majority of premenopausal women with early stage breast cancer who are starting on hormonal therapy. There are two international clinical trials – SOFT and TEXT – that are comparing ovarian suppression plus an aromatase inhibitor with ovarian suppression plus tamoxifen or tamoxifen alone. I would encourage premenopausal women with hormone receptor positive breast cancer to consider these trials.

Question One:

I was diagnosed with inflammatory breast cancer at the age of 32, almost seven years ago. It metastasized to my spine and shoulder after two years of being in remission. I have been on Herceptin, Faslodex and Zometa for the last two years and both my CEA and CA 27/29 markers have remained within normal range.

What I'd like to know is...When can Herceptin be discontinued without risk of its discontinuance triggering another recurrence?

Dr. Winer's Response:

I assume your cancer is HER2 positive by either an IHC test (this measures HER2 protein on the surface of the cancer cell) or a FISH test (this measures the number of HER2 genes in the cell nucleus). In women with HER2 positive metastatic breast cancer, we generally continue Herceptin until there is evidence that the cancer has gotten worse or progressed. When the cancer does progress, many doctors still continue Herceptin with other treatments, though the importance of continuing Herceptin in that situation is uncertain.

I suspect that that this is not the first Herceptin-based regimen that you have received. If that is the case, the role of ongoing Herceptin for you is uncertain. That said, it sounds like you are doing quite well and one always worries about "rocking the boat".

The good news is that there are many ongoing clinical trials looking at new treatments for patients with HER2 positive breast cancer. In the not distant future we are likely to have a number of options for women whose cancer has gotten worse in spite of treatment with Herceptin.

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