Line 2 hormone sequence

cive
cive Member Posts: 709
edited March 2017 in Stage IV/Metastatic Breast Cancer ONLY

So my tumor markers took off like a rocket last month.  I'm scheduled for a CT scan on Monday and then see my MO on Thursday.  I was seeing the NP before getting my Xgeva shot this week and she was suggesting they would move me to Faslodex next.  My question is has anyone gone from Femara to Aromasin as a second line treatment?  There is a short blurb about it in Bestbirds MBC guide, but other than that I've not been able to find much else.  I take a blood thinner so Faslodex would be a real pain in the derriere at least for the loading.  Pun intended.  

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  • zarovka
    zarovka Member Posts: 3,607
    edited March 2017

    Cive - BestBird's guide gives you a road map through the hormonal treatments but you can see from her presentation that it is flexible. Aromasin is, technically, considered to be stronger than faslodex and reserved, generally, for third line. But we have more and more options so if you have concerns about faslodex, skip right to aromasin. Have you considered the hormone suppression with a targetted therapy? There are interesting trials as well as some FDA approved options.

    If you fill out your diagnosis and treatment in your profile AND make it public in your settings (menu on the left), you will get better answers.

    >Z<

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  • cive
    cive Member Posts: 709
    edited March 2017

    Thanks for your reply Z.  I have chosen not to participate in targeted therapy (Ibrance) because I am 67 and I'm not terribly worried about the number of years I have left, but I'm concerned with the quality of that number of years.  Ibrance is very expensive and the benefit/cost ratio is a less for me than for younger people with kids.

    Anyway, I'm luminal A with mets to lung and bone and haven't filled out the diagnosis portion for a couple of reasons.  Primarily, I really don't want my diagnosis memorialized on the internet and I also feel more comfortable responding to non-mets/stage IV posts without giving them something else to worry about. 

    I will discuss Aromasin with my MO but was hoping to also be able to give him some sources to validate that course of action.   I'm taking the blood thinner because I have a greater than normal stroke risk due to atrial fibrillation which means not only will Tamoxifen not be in my future, but the blood thinner makes me more subject to hematomas due to muscle injections. 

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  • Bestbird
    Bestbird Member Posts: 2,818
    edited March 2017

    cive, if you haven't already been on Letrozole, you may want to give that a try because it's an AI which works differently than Faslodex. Although Aromasin is also an AI, it's a non-steroidal AI, and I haven't heard much recently about it being given as a monotherapy. There's also Tamoxifen.

    Here's a brief recap of hormonal therapy for postmenopausal patients.

    Wishing you an excellent outcome, whatever you decide!

    The sequence of providing hormonal (endocrine) therapy for postmenopausal patients will vary, as much of it depends upon what - if any - hormonal therapy drugs the patient has previously taken.Generally, there is a choice of providing single drugs or a combination of drugs, with combination drugs generally precipitating more side effects.Patients are urged to discuss the various options with their doctor and to verify insurance coverage, since it is possible that some of the combination drug regimens listed below may not yet be covered by insurance.

    The following sequence of single or combination hormonal therapy drugs has been lifted from a presentation made by Dr. Maura Dickler of Memorial Sloan Kettering at the 2015 San Antonio Breast Cancer Symposium. Her recommendations are based upon the results of clinical trials as well as her own clinical practice. From: https://sabcs.cmeoncall.com/OnlinePlayer/153

        • Single Agent Hormonal Therapy Sequence:
          • First line treatment should consist of a non-steroidal Aromatase Inhibitor (AI) such as Letrozole or Arimidex
          • Second-line treatment should be either Faslodex (500mg) or Aromasin
          • Third line treatment should be Tamoxifen
          • Fourth line treatment may be either Estradiol, Megestrol Acetate (Megace), or Halotestin (Fluoxymesterone)
        • Combination Hormonal Therapy Sequence:


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  • zarovka
    zarovka Member Posts: 3,607
    edited March 2017

    Cive - With luminal type A, a light touch may control your cancer for a long time. BestBird has laid out the options. Lots of good hormonal options. I do think you can play with the sequence, skip the ones you don't like. It is wise of you to keep in mind all the other issues you have going on and the possible interactions when you make this decision.

    >Z<

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  • cive
    cive Member Posts: 709
    edited March 2017

    Thanks Bestbird and Z!  I guess I forgot to mention that I have been on letrozole for 18 months with initial declines in TMs equivalent to the sudden increase.  I don't have any symptoms just the TMs tripling from 200s to 700s.  Yes I have your guide bestbird, and that's where I found the bit about Aromasin before Faslodex.  I have no symptoms other than the TM rise and maybe a little fatigue.  We'll see what my CT scan shows and my MO says on Thursday.  I will mention the Aromasin to him, take the relative section in MBC guide, and see what he says.  I know which my insurance company would prefer! 

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  • Bestbird
    Bestbird Member Posts: 2,818
    edited March 2017

    cive, the good news is that you have many viable options. Faslodex is certainly one, as is Tamoxifen (if you have been off it for a while if you had taken it for early stage bc). A sister drug to Tamoxifen is Fareston for postmenopausal patients; the latter bypasses any CYP2D6 issues that can confound the body's ability to process Tamoxifen (CYP2D6 deficiency is present in from 3% to 6% of the population).

    I'm thinking that a hormonal drug which is not an AI might be the best option and would be very interested in hearing what your oncologist recommends.

    Wishing you an excellent outcome on your next tx!

    P.S. Generally, increases in TMs themselves should not generally precipitate a change in tx unless scans substantiate the need for a change. Sometimes TMs climb and spike for a bit and then decrease. (It's a bit of a double-edged sword to measure TMs!)

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  • cive
    cive Member Posts: 709
    edited March 2017

    Thanks bestbird!  Tamoxifen is not in my future because of the increased stroke risk. I already have an increased risk due to atrial fibrillation which is why I'm on a blood thinner.  I'm afraid a stroke would greatly decrease my quality of life.  But I will let you know what we decide on after I see my MO Thursday. 

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  • Bestbird
    Bestbird Member Posts: 2,818
    edited March 2017

    cive, please keep us up to date, and best wishes on your upcoming meeting!

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  • cive
    cive Member Posts: 709
    edited March 2017

    So I got the CT scan report and no progression (maybe even improvement in the lungs) other than 1 liver lesion that went from mm to cm.  So MO is advocating Faslodex w/Ibrance.  Didn't feel that Aromasin was a viable option since he thinks the AIs are pretty much equivalent.  Haven't decided about the Ibrance, but have an appointment to get my first faslodex shot next Tuesday.  Of course that is if they can get permission from my insurance company.  Geeze louise, he sent me home with a lab order to get cbc weekly.  Are you kidding me - I thought monthly for my INR was bad, especially since I have one workable vein on the breast cancer side(clot in my vein caused me to get chemo in my veins three times on the non-BC side).

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  • susan_02143
    susan_02143 Member Posts: 7,209
    edited March 2017

    Cive,

    Lots of blood work for the Ibrance, at least to start. Once they know how you respond, I found that the time between the tests did get longer after my second cycle. The Faslodex only needed blood work once a month.

    Best of luck on this combination,

    *susan*

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  • cive
    cive Member Posts: 709
    edited March 2017

    Hey Susan we were first diagnosed at almost the same time-- mine was on new years eve 2004.  Started treatment in 2005.  So how did you tolerate Ibrance other than all the blood tests?

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  • susan_02143
    susan_02143 Member Posts: 7,209
    edited March 2017

    cie,

    Ibrance was the toughest 6 months of my life. I did not tolerate that treatment at all. For the first time ever, I felt really sick. As it happened, it also wasn't working so I moved on to Xeloda which gave me 14 months of reduction and stable. All indications are that my response to Ibrance was unusual. Most folks don't feel so crappy on that drug. There is a very active Ibrance thread which can help you learn more about other people's experiences.

    *susan*

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  • cive
    cive Member Posts: 709
    edited March 2017

    Thanks Susan, yes I've gotten thru the first coupla pages of fas/ibr topic.  I will get all the way through by Tuesday.  My MO told me that I had to go on Fas and Ibr at the same time.  Some of the people on the fas/ibr topic didn't do it that way.  I'd kinda like to try the Fas for a month then check TMs, but MO is dead set against that.  Perhaps because I'd probably stay on Fas only and it would be failing before I started ibr.

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  • susan_02143
    susan_02143 Member Posts: 7,209
    edited March 2017

    Cive,

    It is an odd line in the sand. Faslodex alone [and sometimes with Aromasin] kept me NED for five years with minimal side effects. It would a shame to "waste" the Faslodex if you don't respond to Ibrance, but then again, I don't have an MD at the end of my name.

    *susan*

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  • zarovka
    zarovka Member Posts: 3,607
    edited March 2017

    Cive - That is not a super logical response from your onc. i was on letrozol alone for three weeks just because my insurance company took its time to approve ibrance, but the letrozol i could start immediately. i think there is a benefit to seeing how you feel on faslodex before you add the ibrance layer. there is a lot going on as you adjust to hormone suppression.

    it is not a a big deal to wait and start together.

    but an odd line in the sand indeed. if the onc continues to be weird, consider other options.

    >Z<

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  • cive
    cive Member Posts: 709
    edited March 2017

    I'm scheduled for my first faslodex shot on Tuesday.  And I would like to see how faslodex alone will handle things.  My TMs have always been really responsive so it wouldn't take long to know if I'm responding to the faslodex with out Ibrance.  My TMs dropped by almost half after 1 month on femara and now almost tripled with the progression in my liver. 

    I still have a few days before I decide about the Ibrance, I could just get the faslodex when I go in on Tuesday.  I have been reading the fas/ibr thread and I see that several ladies started on faslodex and then added ibrance later. 

    And yeah things got a bit tense between MO and I in our discussion.  I just wanted to ask him about Aromasin and he wanted to give me his spiel.  Unfortunately he is the only MO in my medical group so changing MOs would really be a pain and take several months (he even suggested I might want to do that).  Most of my dealings are with his NP anyway and she and I get on famously.  I let you know what I decide on Tuesday.

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  • susan_02143
    susan_02143 Member Posts: 7,209
    edited March 2017

    cive,

    The Faslodex takes about 3 months to show up in the blood work give or take. I too, have numbers that respond quickly, and at three months, we knew that it was working.

    *susan*

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  • cive
    cive Member Posts: 709
    edited March 2017

    So I did start Faslodex and Ibrance yesterday.  My thinking being that I can also drop the Ibrance in the future since my MO got approval for both from my insurance company as a combo.  Kind of a drag to stand there like a heron but other than that the faslodex shots didn't really bother me.  I got the second one fairly fast because I started coughing in the middle of it and couldn't stop.

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  • susan_02143
    susan_02143 Member Posts: 7,209
    edited March 2017

    All the best to you cive. I hope that this protocol works well for you with minimal side effects.

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