Progression/liver Mets

Daughter -

Local treatment of mets is generally used when the tumors interfere with the function of an organ or are causing pain. The good news is that the liver can be loaded with tumors and still work pretty well. Systemic chemo is really effective when cancer is growing fast and your Mom's MO has a reasonable plan. Local control is always an option down the line.

That said, second opinions and third opinions are a good idea at any cross road in treatment. When MBC is late stage, an NCI cancer center is THE place to go. Get more perspectives until you are completely comfortable with the treatment plan.

Also, carpenters like hammers and plumbers like wrenches. Same goes for the different types of doctors. Most people have an MO handling their care and MO's like ... systemic chemo. It's because that is what they were trained in. If you are curious about local treatment of mets go directly to someone who specializes in that treatment.

Finally, ask the MO whether it makes sense to biopsy the new mets, maybe consider functional or genetic testing. The cancer may have changed and that may inform a treatment decision. Many oncologists do shoot blind at new progression and I am sure they do this based on their extensive experience, but it is not what I would do.

Consult with other doctors and specialists, but know that your mother's doctor has certainly proposed something reasonable. You might consider going with his/her plan while seeking other opinions at the same time.

(hugs). Take care of yourself.

>Z<

I am sorry to hear of your mother's progression, and might suggest that she seek a second Medical Oncologist's opinion as well as that of a Radiation Oncologist.

In addition to systemic treatment, there are several liver-directed therapies. Below from my MBC Guide is a list of these. You (and others) are welcome to request a complimentary copy of the 126-page booklet by visiting: https://community.breastcancer.org/forum/8/topics/831507?page=3#idx_73

• Ablative Therapies

• Cryotherapy
• NanoKnife
• RadioFrequency Ablation (RFA)

• HAI Chemotherapy
• NKTR-102 (Etirinotecan Pegol) – Not Yet FDA-Approved
• Radioembolization or SIRT/Yttrium 90 Microspheres (Theraspheres)
• Transarterial Chemoembolization (TACE)

The above procedures are described below:

• Ablative Therapies:Ablative therapies can be performed percutaneously (through the skin) or as an open surgical procedure by a surgeon who specializes in oncology.A special probe is used to access the tumor, and the specific method of treatment as described below is delivered by the probe.Ablation is generally safe and well tolerated.It may be an effective treatment for patients with inoperable metastatic tumors, but this treatment is limited by the size and number of tumors present.

• Cryotherapy:Cryotherapy, also called cryosurgery, cryoablation, or targeted cryoablation therapy, uses the application of extreme cold to destroy the liver tumor.
• NanoKnife: NanoKnife works by applying electrical energy directly into tumors and opening cell walls of the tumor. The cancer cells die; and the healthy tissue remains unharmed.
• Radio Frequency Ablation (RFA):Radiofrequency ablation, also known as RFA, is a technique of heating up liver cancers with probes inserted into the tumors.

• HAI Chemotherapy: Hepatic Arterial Infusion (HAI) involves a drug delivery system that is implanted under the skin.A catheter from the pump is connected to the gastroduodenal artery, which joins the hepatic (liver) arteries, allowing the pump to infuse only the liver with chemotherapy. One study reviewed the treatment histories and outcomes of nine patients with heavily treated breast cancer liver metastasis who received hepatic arterial infusion (HAI) of floxuridine (FUDR)/dexamethasone (Dex) and systemic chemotherapy. Patients received a median of five HAI treatments, and there were seven (78%) objective responses.Four patients had grade 3 elevations in liver enzymes attributable to HAI.There were no treatment-related deaths.Median survival after starting HAI was 17 months and median Overall Survival from the original breast cancer diagnosis was 110 months. Furthermore, one patient is alive with stable disease on systemic therapy alone. Therefore, HAI and systemic chemotherapy are feasible and can benefit selected patients who have progressed on prior therapies.Patients undergoing the procedure require close monitoring for treatment-limiting toxicities.From: http://www.ncbi.nlm.nih.gov/pubmed/23173748

• NKTR-102 (Etirinotecan Pegol) – Not Yet FDA-Approved: In a clinical trial called BEACON, 852 patients with advanced breast cancer who had any type of ER/HER-2 status were enrolled. Patients were randomly assigned to receive either NKTR-102 or a physician's choice of standard chemotherapy. The study found that NKTR-102 increased Overall Survival in patients with liver metastases when compared to the physician's choice chemotherapy.Furthermore, NKTR-102 was less toxic than standard chemotherapy. As of Jan. 2017, several clinical trials are underway for patients with metastatic disease.

From: http://www.healio.com/hematology-oncology/breast-cancer/news/online/{f8e52d75-2273-432b-9473-b50f936c0765}/novel-chemotherapy-drug-demonstrates-activity-in-advanced-breast-cancer and https://www.clinicaltrials.gov/ct2/show/NCT01991678?term=nktr102&rank=4

• Radioembolization, SIRT/Yttrium 90 Microspheres (Theraspheres):This is a relatively new treatment suitable for use even in patients with extensive liver involvement.Radioactive spheres (very tiny radioactive "seeds") are injected into an artery in the liver.After they are injected through the liver artery, the seeds travel into smaller arteries that feed the tumor.Once they reach the tumor, they give off radiation for about three days.The radioactivity causes damage to cancer cells with little damage to the healthy liver tissue.Radioembolization was safe and provided disease stabilization in 98.5% of the patients' treated liver tumors in a recent study.From: http://www.sciencedaily.com/releases/2014/03/140324133234.htmThat said, the author has read several patient accounts commenting that the procedure was not successful for them, and many patients disclosed that they were greatly fatigued afterwards.Therefore, anyone considering this procedure should gather as much information as possible about the success rate and after-effects experienced by prior patients at the clinic that offers this procedure.One person whose liver mets were allegedly too large for the procedure wrote this valuable tip: "I had trouble finding a doctor who would do it given the size of my tumors as well as some insurance coverage issues - and I got 3 "no's" from different doctors until I contacted the company who makes the radioactive beads, SIRTEX. Their sales representative hooked me up with a highly skilled interventional radiologist named Ryan Majoria who eventually accepted me.SIRTEX has great customer service and can also provide the name of one of their representatives in the patient's geographic area who will call and talk to the patient personally about their product and whether or not the patient might be a good candidate (of course they are not doctors, but these reps know EVERYTHING from my experience including who the most experienced doctors are who perform the procedure.) SIRTEX's telephone number is: 1-888-474-7839. Patients should ask for the representative in their area to call them.My Y90 procedure went well, and my main side effect is fatigue."For those who may be interested, an excellent video about Radioembolization is located at: https://www.youtube.com/watch?v=3WwSfGPQq9g
• Transarterial Chemoembolization (TACE):In this technique an interventional radiologist injects a chemotherapeutic agent directly into the arteries supplying the tumors within the liver.Embolization therapies such as TACE have been used for the last two decades by interventional radiologists to treat liver tumors.

Dear Daughter,

I was in your mother's position last year. After four years of bone only, I had liver progression after a failed run at Letrozole/Ibrance. The only anti-hormonal I've ever gotten a good run from was Faslodex.

MO was certain that Halaven was the way to go. He was right. Halaven knocked the liver progression all the way back, settled some new bone mets, and got me to feeling stronger and healthier than I had in years. I did 7 cycles, and then went to CMF for maintenance. It has been 6 months for the CMF, and my TMs are still in the normal range.

I had trouble with anaemia on the Halaven, but it did the job, and quickly too. With liver progression, it is good to put the fire out quickly, which is why my MO wanted to go the chemo route. Also, I was kind of out of anti-hormonals; they have never been as successful for me as I would wish.

Your Mom is in good hands. By choosing Halaven, her MO has demonstrated that she's reading all the latest research. This is a good drug, and I honestly feel that I owe my present state of health to it.

If she has any questions, PM me. I would love to burble on about how great I think this chemo is, and how shocked I am that more MOs aren't using it for third-line treatment. This drug is a life saver.

Jennifer

Daughter - Let us know how it goes. I hope the treatment is easy and effective.

>Z<