Table 3 Proposed treatment choices for the management of HR + HER2 − mBC in selected case scenarios
Sl. No. | Description of the case scenario | Proposed treatment choices | Other preferred first-line choices | Other preferred second-line choices | Other preferred third-line choices |
|---|---|---|---|---|---|
Case 1 | A 38-year–old woman with stage II breast cancer (ER +/HER2–) treated with surgery, radiation, 4 cycles of cyclophosphamide followed by 12 weeks of paclitaxel, and AI/goserelin, and with 1-year DFS returns with four liver mets and multiple bone mets. Biopsy reveals ER+/HER2–, ki-67: 50%. What would be the choice of treatment in this patient? | First choice: CDK4/6 inhibitor plus fulvestrant Second choice: Everolimus plus fulvestrant Third choice: Fulvestrant alone | – | Participation in a clinical trial or the use of PIK3CA inhibitors in patients with confirmed PIK3CA mutations. | – |
Case 2 | A 65-year–old woman with stage I ER+/HER2– breast cancer treated with tamoxifen and with a DFS of 12 years returns with 2 bone and 1 lung mets and low-volume disease. What would be the choice of treatment in this patient? | First choice: CDK4/6 inhibitor plus AI or CDK4/6 inhibitor plus fulvestrant in patients intolerant to AI Second choice: AI or fulvestrant single-agent therapy if CDK4/6 inhibitor is not available | – | – | • Exemestane • Everolimus + Exemestane |
Case 3 | A 32-year–old woman presents with stage IV de novo mBC with a 3-cm breast mass (ER/PR+ and HER2–) and bone mets in the hip, T4, and sacrum. What would be the choice of treatment in this patient? | First choice: CDK4/6 inhibitor plus fulvestrant Second choice: Fulvestrant single-agent therapy if CDK4/6 inhibitor is not available | GnRH-A + AI + CDK4/6 inhibitor | If fulvestrant is used in 1st line, GnRH-A ± tamoxifen or AI | GnRH-A + AI, or a clinical trial of exemestane + everolimus |
Case 4 | A 55-year–old woman with recurrent ER+/HER2– breast cancer who was on adjuvant anastrozole and with a DFS of 5 years presents with extensive liver and bone mets, but not in visceral crisis. What would be the choice of treatment in this patient? | First choice: CDK4/6 inhibitor plus fulvestrant Second choice: Everolimus plus fulvestrant, in case of no access to CDK4/6 inhibitor | – | Everolimus + exemestane | Tamoxifen |