Cytotoxic chemotherapy: Still the mainstay of clinical practice for all subtypes metastatic breast cancer

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Highlights

  • In the era of targeted treatments, chemotherapy remains the backbone for treatment of breast cancer being an option for all molecular subtypes of the disease. This review is intended to:

  • Give a practical guideline for treating women with metastatic breast cancer (MBC) helping clinicians to make evidence based decisions following treatment with an anthracycline and a taxane.

  • Provide an update on cytotoxic drugs recently evaluated in late line MBC.

  • Identify priorities in the development of new cytotoxics for women with MBC.

Abstract

Cytotoxic chemotherapy remains central to the treatment of all subtypes of metastatic breast cancer (MBC). We review evidence-based chemotherapy options for women with MBC after an anthracycline and a taxane including re-challenge with anthracycline or taxane, capecitabine, eribulin and ixabepilone as a single agent or combination with capecitabine (not approved in the EU); and the vinca alkaloid vinflunine as single agent or combined with either capecitabine/gemcitabine (also not approved EU or USA). Etirinotecan pegol, comprising irinotecan bound to polyethylene glycol by a biodegradable linker, is a new cytotoxic agent for patients with MBC that has achieved encouraging response rates in phase II studies; it has been further evaluated in the phase III BEACON trial. New cytotoxics should address novel targets or modes of delivery, achieve meaningful improvements in outcomes and seek to identify predictive biomarker(s).

Abbreviations

5FU
5-fluorouracil
A
anthracycline
BEACON
BrEAst Cancer Outcomes with NKTR-102
BRCA
breast cancer gene
CALGB
cancer and leukemia Group B
CTCs
circulating tumor cells
CI
confidence interval
CHF
congestive heart failure
DFI
disease-free interval
EMBRACE
Eisai Metastatic BReast Cancer study Assessing physician’s Choice vs E7389
EPR
enhanced permeability and retention
NKTR-102
etirinotecan pegol
EMA
European Medicines Agency
EU
European Union
q21d
every 3 weeks
FDA
Food and Drug Administration
1L
first-line
HFS
hand–foot syndrome
HR
hormone receptor
HER2
human epidermal growth factor receptor 2
ITT
intention-to-treat
MBC
metastatic breast cancer
nab-P
nab-paclitaxel
NPLD
non-pegylated doxorubicin
NR
not reported
NS
not statistically significant
ORR
overall response rate
OS
overall survival
PPE
palmer-plantar erythrodysesthesia
PLD
pegylated liposomal doxorubicin
PN
peripheral neuropathy
PFS
progression free survival
QOL
quality of life
T
taxanes
TTP
time to tumor progression
TOP1
topoisomerase I
T-DM1
trastuzumab emtansine
TPC
treatment of physicians’ choice
TNBC
triple-negative breast cancers
US
United States

Keywords

Metastatic breast cancer
Anthracycline
Taxane
Capecitabine
Eribulin
Etirinotecan pegol

Cited by (0)

Chris Twelves is Professor of Clinical Cancer Pharmacology and Oncology and Head of Clinical Cancer Research Groups at the Leeds Cancer Research UK Centre. He is a medical oncologist with a particular interest in new drug development and clinical pharmacology; his clinical practice has been in colorectal and breast cancer. After training as an oncologist in London he was Senior Lecturer, then Reader, in Medical Oncology in Glasgow at the Beatson Oncology Centre before taking up his current post at the University of Leeds and St James’s Institute of Oncology. Prof Twelves also heads the Leeds Experimental Cancer Medicine Centre in Leeds and has been a member of the Cancer Research UK New Agents Committee and Chair of the New Drug Development group of the EORTC. He has been involved in the development of several important new agents including capecitabine, and eribulin. Professor Twelves has published over 150 papers in journals including the New England Journal of Medicine, Lancet and Journal of Clinical Oncology and spoken at numerous international meetings. He has also edited, or contributed to, several books.

Maria Jove studied medicine at the University of Barcelona, Spain. She completed her specialization in medical oncology within the Spanish registrar program in 2012 at “Institut Catala d’Oncologia”, Barcelona. Maria worked as a Clinical Fellow in this institute for two years in the Lung and the Sarcoma/Genitourinari groups before moving to the UK to take up a position in St James’s University Hospital in Leeds as a Clinical Fellow in the Phase 1 unit under the supervision of Professor Christopher Twelves. Maria has also been involved with the Neuro-oncology and the Breast Cancer Groups under the supervision of Professor Susan Short and Professor Twelves, respectively. In April 2015 Maria commenced her PhD project, “Intratumoral drug penetration and distribution”, with the Pharmacokinetics Group (Lead, Professor Paul Loadman) at the Institute of Cancer Therapeutics (Hon Clinical Director, Professor Twelves) in Bradford, for which she received a grant from the Spanish Medical Oncology Society. Maria is a certified member of the ESMO and Spanish Medical Oncology Society.

Andrea Gombos is medical oncologist working for five years at the Institut Jules Bordet in Brussles. Her research activity is mainly focused on the coordination as principal investigator of several academic trials and internationally conducted clinical trials, evaluating new treatments and treatment combinations in the management of metastatic and early stage breast cancer. She is involved in the development of some international trials and is coordinator for a multicentre Belgian project including a large translational part aiming to understand resistance to the mTOR inhibitor everolimus in metastatic breast cancer. She is a certified member of the ESMO and full member of AACR.

Ahmad Awadais the Head of Medical Oncology Clinic Jules Bordet Cancer Institute Brussels, Belgium Professor Ahmad Awada was born in Lebanon and studied Medicine at the Université Libre de Bruxelles (ULB), Belgium. He did a specialisation in Internal Medicine and Medical Oncology at Jules Bordet Institute (under the supervision of Professor Jean Klastersky), in Brussels, until 1992 (“La plus grande distinction”). During his specialisation, he also had training in the clinical development of new anticancer drugs. As a research fellow, he worked in the Netherlands (New Drug Development Office, Free University, Amsterdam) and in San Antonio, USA (Institute for Drug Development). He focused on the clinical development of new anticancer agents. Back from the USA at the beginning of 1994, Dr. Awada became Assistant Head of Medical Oncology Clinic, and Head of the New Drugs Development Unit at Jules Bordet Institute, Brussels. Since April 2005, he has been the Head of the Medical Oncology Clinic. In addition and from 1st March 2011, Dr Awada was appointed Associate Head of Medicine Department. He has an important clinical activity in the treatment of solid tumors and in particular breast cancer. Dr. Awada took an active part in the development of new drugs, some of them already widely used, namely molecular-targeted therapies. Dr. Awada is a member of several international scientific (ASCO, EORTC, ESMO) societies and and Professor of Clinical Medicine at the Université Libre de Bruxelles. He published 26 book chapters and, 221 articles in international publications.