From the Guidelines
The first-line treatment approach for an 88-year-old male patient with metastatic, hormone receptor-positive (HR+) and HER2-negative breast cancer should be endocrine therapy, specifically with tamoxifen, an aromatase inhibitor combined with a gonadotropin-releasing hormone agent, or fulvestrant, as recommended by the ASCO guideline 1. The choice of endocrine therapy should take into account the patient's performance status, comorbidities, and quality of life goals.
- Endocrine therapy is preferred over chemotherapy in this setting due to its favorable side effect profile and effectiveness in controlling hormone-driven cancer growth.
- Regular monitoring for treatment response should occur every 2-3 months with clinical exams and appropriate imaging.
- Bone-targeted agents like zoledronic acid or denosumab should be considered if bone metastases are present to reduce skeletal-related events. The ASCO guideline update 1 also supports the use of endocrine therapy as first-line treatment for patients with HR-positive, HER2-negative metastatic breast cancer, except in cases of visceral crisis or rapidly progressive disease.
- The guideline recommends that treatment decisions should be based on the biology of the tumor and the patient's menopausal status, with careful attention paid to production of estrogen.
- The choice of second-line hormonal therapy should take into account prior treatment exposure and response to previous endocrine therapy. Given the patient's advanced age, it is essential to carefully consider their overall health and quality of life when making treatment decisions, and to prioritize treatments that are likely to provide the most benefit with the fewest side effects, as recommended by the ASCO guideline 1.
From the FDA Drug Label
INDICATIONS & USAGE 1.1 Adjuvant Treatment Anastrozole tablets are indicated for adjuvant treatment of postmenopausal women with hormone receptor-positive early breast cancer. 1.2 First-Line Treatment Anastrozole tablets are indicated for the first-line treatment of postmenopausal women with hormone receptor-positive or hormone receptor unknown locally advanced or metastatic breast cancer. The FDA drug label does not answer the question.
From the Research
Treatment Options for Metastatic HR+ and HER2- Breast Cancer
- For an 88-year-old male patient with metastatic, hormone receptor-positive (HR+) and human epidermal growth factor receptor 2-negative (HER2-) breast cancer, the first-line treatment approach typically involves hormone therapies with or without targeted therapies 2.
- Estrogen receptor modulators and estrogen deprivation have become standards of care for hormone receptor-positive metastatic breast cancer 3.
- CDK4/6 inhibitors plus hormone therapies are better than standard hormone therapies in terms of progression-free survival, and no chemotherapy regimen with or without targeted therapy is significantly better than CDK4/6 inhibitors plus hormone therapies in terms of progression-free survival 2.
- Treatment options may include:
- Palbociclib plus letrozole
- Ribociclib plus letrozole
- Abemaciclib plus anastrozole or letrozole
- Palbociclib plus fulvestrant
- Ribociclib plus fulvestrant
- Abemaciclib plus fulvestrant
- Everolimus plus exemestane
- Alpelisib plus fulvestrant (in patients with a PIK3CA mutation) 2
Considerations for Treatment Selection
- The optimal treatment sequence to maximize clinical benefit is a clinical challenge, and multiple studies have aimed at optimizing treatment strategies to improve upon clinical benefit beyond traditional single-agent endocrine treatment 3.
- The treatment landscape of HR+/HER2- breast cancer is evolving, with several new agents being studied and potential for future regulatory approval 4.
- Recently approved targeted therapies have demonstrated improvements in progression-free survival for patients whose cancer harbors mutations in the PI3K/AKT pathway, ESR1, BRCA1/2, and/or PALB2 4.