Oligomets: differences in Rx approach

I read so much about how aggressively they treat oligomets in the U.S. - aiming for ‘curative’ treatment just like they would with a primary BC that hasn’t spread. But it wasn’t even ‘mentioned’ at my consultation when they informed me I have a solitary (2-3cm) liver lesion showing on PET scan [I’ll have it biopsied next week; also had liver MRI last week - will find out results on Thursday].

They said my protocol will now change from curative EC [Epirubicin + Cyclophosphamide] followed by Paclitaxol & PHESGO (then surgery); to life-extending Docetaxol & PHESGO.

I’m F53 +++ (Ki67 = 30% in my primary breast tumour). I feel like they’ve given up on me. I’m due to start chemo 4 days after my liver biopsy. I’ve asked for a curative protocol if the MRI doesn’t show any more liver mets than the single one seen on PET. And they said “I suppose we could try ONE round of EC to see how you respond to it”. Is this just how we manage oligomets in this country?

Or is it something to do with the fact that I seem to be spreading via blood vessels only (no involved lymph nodes on any scan - though appreciate there could be non-visible micro-mets in the LN’s)… and although that’s rare, is it necessarily a poorer prognosis than someone whose spreading via lymph?

Is this a UK-wide approach, or are there regional variations? I’m in central London for what it’s worth; but I’d move across the country if it meant I could be offered a ‘curative’ treatment protocol. I’m only 53. +++

Look up fran Whitfield on Instagram- she had a similar thing. She found her bc aged only 26 as it was in brain and liver but sole met in each. Was also told not curable but it hadn’t gone through her lymph nodes. She moved to royal marsden and they surgically removed the brain tumour and put her on a curative treatment path of abemaciclib and hormone therapy- she is ER positive so slightly different but she is two or three years ned now. You could message her about if I’m sure as she’s very open in posting about her diagnosis. Good luck

Ooh interesting. I’m not on instagram but I’ll google her name and see if she shows up on any other social media (Facebook? Here?)

Others have said EC is ‘old style’ chemo and not necessarily the best (with Paclitaxel & PHESGO afterwards) ‘curative’ protocol in any case … but I think that’s mostly U.S. peeps commenting (on another forum I’m in). They also keep mentioning Enhertu (herceptin with a chemo agent attached to it) as a good protocol for those with mets, but I don’t even know if that’s available in this country on the NHS?

Hi @Ross24

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I have TNBC that spread to my liver through vascular invasion. When the first met in my liver was found (whilst I was still being treated for the primary cancer), I was offered, and accepted a microwave ablation procedure (liver resection not offered even though the met was in zone 8, which would be amenable to resection). The met regrew after ablation, plus I acquired a second one in zone 6. I then had a few months on Pembrolizumab plus NAB-Paclitaxel, which I had to stop following a serious immunotherapy related adverse event. Ironically they are reviewing ablation as an option again, as I only have the 2 mets and no evidence of disease elsewhere.

Hi aross

Thanks for posting, it sounds like you are having a difficult time at the moment. It’s not unusual for people to feel that their team are giving up on them and often they explain they are confused about the changes in treatment choices made.

When breast cancer has spread to another part of the body, this is called secondary breast cancer (also referred to as metastatic or advanced breast cancer). Currently, secondary breast cancer is treatable but not curable.

Treatments for primary breast cancer such as surgery, radiotherapy and drug treatments are given with the intent of achieving cure, even though doctors can’t say for certain this will happen for each individual.

Systemic therapy (drugs that work throughout the body) are the main treatment used for secondary breast cancer which aims to control and slow down the spread of the cancer, relieve symptoms, maintain health and wellbeing and give you the best quality of life for as long as possible.

Research evidence has helped breast cancer experts across the world agree on the best treatments and their sequencing for different types of secondary breast cancer. The guidance experts produce is updated every couple of years following a consensus meeting when the latest research is examined. You can read the current guidance here ESMO Clinical Practice Guideline for the diagnosis, staging and treatment of patients with metastatic breast cancer☆ (annalsofoncology.org)

Guidance on treatment for management of secondary breast cancer is not made based on how the cancer has spread (through the blood system or lymph nodes), but on factors such as where the secondary breast cancer is in the body, how extensive it is (how many sites and how large), the features of the secondary breast cancer and what previous treatment someone has had. You can read a little more about this here. These factors can also affect your prognosis.

Whilst EC, paclitaxel and Phesgo (trastuzumab and pertuzumab) is a very common drug regime currently used for early HER 2 positive breast cancer, docetaxel and Phesgo is the agreed best regime for those newly diagnosed with secondary breast cancer as you’ll read on page 1481.

Enhertu is available for use on the NHS, but is given to people who have already had one or more treatments specifically for HER2 positive breast cancer.

However, like you, there are a number of people who present with solitary or a small number of secondary cancers often called oligometastatic disease (OMD), some of whom go on to achieve complete remission and a long survival. OMD is not very well understood, but treatment can include several approaches (often referred to as an aggressive approach) used for curative intent such as surgery to the breast and axilla, radiotherapy in additions to treatments such as microwave ablation as @Coddfish mentions, as well as drug treatment to try and achieve the best response. Some drug treatments can be used for both primary and secondary breast cancer such as the combination of abemaciclib and letrozole that @helen39 mentions in her post.

As every situation is different, there is currently no one agreed protocol for managing oligometastatic disease. However, guidance does state that patients with OMD should be discussed by the multidisciplinary team (MDT) to tailor their treatment recommendations to the individual. You can read more about this via the above link to the guidance on page 1488 and 1489.

It sounds as though it would be a good idea to speak with your treatment team again to ask them to explain fully the rationale for the treatment options you mention and ask if this has been discussed by the MDT. If you still have concerns, you may wish to request a second opinion to help you feel you are getting the most appropriate treatment and care.

Do call our helpline if you would like to talk this through or have any further questions. The helpline team have time to listen, talk things through and signpost you to more support and information if necessary. Your call will be confidential, and the number is free from UK landlines and all mobile networks. The number is 0808 800 6000, (Relay UK - prefix 18001).

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Best wishes

Catherine

Breast Care Nurse

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