Novel Microtubule-Targeting Agents in Metastatic Breast Cancer: Nurse Centric Case Discussions

Dr. Rosenzweig is an assistant professor and director of the oncology nurse practitioner program at the University of Pittsburgh School of Nursing in Pennsylvania. She received her doctorate in nursing from the University of Pittsburgh. Her primary research interest is palliative chemotherapy in metastatic breast cancer. Dr. Rosenzweig is an active member of the Cancer Working Group, American Nurses Association, and Pennsylvania Nurses Association.

Margaret Rosenzweig reported no areas of conflict.

Metastatic Breast Cancer Treatment Overview

Metastatic breast cancer (MBC) is a heterogeneous disease responsive to a number of therapies. Historically, patients diagnosed with MBC have been assigned to treatment with either curative or palliative intent, and clearly defined algorithms. The mortality rate for women with MBC is decreasing steadily at a rate of 2.3% annually, attributed in part to more efficacious systemic therapies. Treatment algorithms for MBC have been organized according to individual tumor characteristics and previous therapy, including hormonal status, HER2 status, previous therapy in the adjuvant setting, and response to initial and subsequent metastatic treatments. The algorithm includes initial and sequential endocrine and chemotherapy, including anthracyclines, taxanes, capecitabine, vinorelbine, gemcitabine, and ixabepilone. The most appropriate therapeutic approach is dependent upon of a number of patient-, tumor-, and treatment-related factors. The importance of quality of life and end of life care is also emphasized. In addition, there are exciting new endocrine, chemotherapeutic, and biologic therapies offering new options for the MBC treatment algorithm. This presentation will examine evidence-based treatment algorithms in MBC utilizing tumor characteristics and previous breast cancer therapy as the organizing framework. Newer biologic agents and their use within the MBC setting will also be discussed.

Breast Cancer Survivorship Pyschological Support Update

In recent years, cancer survivorship issues have received greater attention and research interest as the number of cancer survivors increases in the United States, and the cancer advocacy movement gains in strength. Cancer survivorship is defined as a continuum from the time of diagnosis to the end of life. It has been conceptualized as a progression through three phases or “seasons” of survival incorporating: (1) surviving the treatment and its side effects, (2) beginning to return to normal life while being monitored for recurrence, and (3) long-term adjustment, when the cancer experience is viewed as an episode in a full life. In 2004, the most recent year with complete Surveillance, Epidemiology, and End Results (SEER) data, there were 10.1 million cancer survivors; of these, more than 2.4 million were breast cancer survivors. Family members, friends, and caregivers of the woman diagnosed with breast cancer are also considered to be cancer survivors.

Psychosocial distress, at varying levels of severity, accompanies the cancer experience. There are calls to consider distress the sixth vital sign; it would then be routinely monitored along with pulse, blood pressure, respiration, temperature, and pain. Periods of highest distress for the woman with breast cancer are associated with transition points in treatment. Completion of treatment may be a cause of increased anxiety rather than joy. There are many potential barriers to meeting the psychosocial needs of women with breast cancer after active treatments ends. The Institute of Medicine of the National Academies has released several reports during recent years describing strategies to acknowledge and meet these needs, declaring that provision of psychosocial services should be a standard of care for survivors of cancer. Oncology nurses play a key role in assessing the patient, family members, and caregivers for signs of distress. In so doing, an atmosphere of compassion and trust is created such that the breast cancer survivor feels free to share psychosocial concerns and have them addressed by appropriate specialists if necessary.

Dr. Vahdat is associate professor of clinical medicine and director of the Breast Cancer Center at Weill Cornell Medical College in New York City. She attended medical school and completed her training in internal medicine at Mount Sinai School of Medicine in New York City. Dr. Vahdat then completed a fellowship in Hematology and Medical Oncology at Memorial Sloan-Kettering Cancer Center, also in New York City. She is involved in the design and conduct of phase I through III clinical trials in breast cancer and has expertise in peripheral neuropathy and the evaluation of new agents. Dr. Vahdat also serves as associate editor for the American Society of Clinical Oncology Web site, People Living With Cancer (PLWC.org).

Linda Vahdat reported no areas of conflict.

Novel Treatment Strategies for Taxane Resistance

It is estimated that more than 220,000 cases of breast cancer were diagnosed in 2007. The median survival of patients with metastatic breast cancer has improved with the introduction of new agents, however, treatments are often associated with a narrow margin between benefit and toxicity. In addition, drug resistance is linked to more than 90% of treatment failures in patients with metastatic disease. Epothilone chemotherapy, with broadspectrum antitumor effects, represents new therapeutic options for patients with breast cancer. Ixabepilone, an analogue of epothilone B, is a recently approved agent that is active as monotherapy in anthracycline- and taxane-refractory breast cancer and is also effective when combined with capecitabine. The primary adverse effects associated with ixabepilone are neuropathy and neutropenia. Although significant strides have been made in the treatment of breast cancer, there is still a need for new therapeutic agents. Several epothilones are under investigation and offer hope for the future. It is also expected that with improved screening methods, clinicians will be able to identify subsets of patients for whom treatment will provide the greatest benefit.

Update on Clinical Trials of Antiangiogenesis Agents in Breast Cancer/Metastatic Breast Cancer Treatment Update

Metastatic breast cancer (MBC) remains a largely incurable disease. However, survival rates continue to increase as advances in the understanding of the biology of tumorigenesis are made. Angiogenesis plays a major role in tumor formation and therefore, agents targeting this process, including the monoclonal antibody bevacizumab, are particularly successful at treating tumors. In addition, the introduction of the monoclonal antibody trastuzumab has dramatically improved outcomes for women with human epidermal growth factor receptor 2 (HER2)-positive MBC and reaffirmed the value of targeting specific cellular proteins as a means of controlling disease. This has led to the development of a plethora of new agents for the treatment of HER2-positive breast cancer in the metastatic setting, though optimal chemotherapy regimens are still under investigation.

Ms. McGettigan is an oncology nurse practitioner for the University of Pennsylvania Health System in Philadelphia. She received her master’s degree in nursing from the University of Pennsylvania School of Nursing in Philadelphia. She has presented nationally on various topics including breast cancer risk, prevention, and treatment. Ms. McGettigan is a consultant for the OncoLink, Ask the Experts Web site. She is also a member of the Oncology Education Service Program Review Board for the Oncology Nursing Society.

Suzanne McGettigan reported a financial interest/relationship or affiliation in the form of: Consultant, Pfizer, Inc.; Speakers' Bureau, Genentech BioOncology.

Oncology Nurse-Centric Case Discussions on Novel Agents

Breast cancer is the most common cancer affecting women in the United States and ranks as the second cancer-related mortality. It was estimated that 178,480 women were diagnosed with breast cancer in 2007. Despite advances in early diagnosis and treatment, approximately 40,910 deaths will be attributed to breast cancer in 2008. Continued investigation into better treatments for breast cancer is imperative. Since their discovery, microtubule-targeting therapies, specifically taxanes and vinca alkaloids, have been in widespread use for the treatment of metastatic breast cancer. A new class of antineoplastic agents known as epothilones has recently been investigated and the first epothilone has been approved for the treatment of metastatic breast cancer. This presentation will use case studies to review the common toxicities associated with microtubule-targeting therapy and the nursing interventions available for them.