Letrozole and Ibrance

HelenFaith · June 2017

Currently, I am on doing Taxol and have completed 9 doses, with 3 more doses scheduled with PET scan repeat during my off week. My MO does have me scheduled to continue Taxol for as long as needed and once it looks as though we have reached our goal of treating the cancer MO wants to put me on Tamoxifen.

My husband and I have made the decision to go to MD Anderson (scheduling appts). I have had phone conversations with a breast doctor there who says there are a couple of things he would different. First, he would order a biopsy of the largest tumor and second he would choose Letrozole and Ibrance and take a hard look at what my lung is doing.

When I was originally diagnosed with MBC, I had been misdiagnosed with pneumonia & a collapsed lung, but after a week of not getting better, more tests were done and I was diagnosed with a Pleural Effusion and MBC. My lung had to be drained twice and both fluids were tested. The first fluid was positive for cancer, so cells were further tested to determine it was MBC. My MO states we don't need a biopsy because the lung fluid gave us all we need to know, but doc at MD says more info is gathered from a biopsy of the tumor.

MDA doc also states ovary removal would be best practice before starting hormone treatment. MO here states ovary removal isn't necessary as Taxol would suppress my ovaries and Tamoxifen would continue the suppression enough to keep estrogen down.

There are a few differences between to two docs, but we want the most aggressive treatment.....right? Can others please share their experiences with me? What about Letrozole & Ibrance versus Tamoxifen?

pajim · June 2017

HelenFaith, you are asking a complicated question so bear with me. Others will have thoughts on this too.

Both plans are valid in their own way. You have ER+ disease, so anti-hormonal therapies should work for you. I'm not clear why you are on Taxol at all, but I assume your MO wanted to cut down the tumor burden before putting you on hormonal therapies.

Lets start with the local MO plan. Tamoxifen is a hormonal therapy and will block the cancer from growing. It's the 'smallest potatoes' in terms of side-effects out there. The label says you do not need to suppress your ovaries to take it. This is a valid approach, it's just not the latest and greatest valid approach. Your local MO is a little old-fashioned. That does not mean wrong or bad. It's a question of style.

The latest and greatest valid approach is to start with letrozole and palbociclib (Ibrance). If you want to take letrozole you must have ovarian suppression. The label and common sense says so. Be aware that letrozole and tamoxifen have about the same side-effects, but palbociclib will add on more side-effects. Fatigue, low blood counts, etc. It's not a trivial difference.

Next. We each have our own individual goals of treatment. In general the goal is to live as long as possible as well as possible. Each of us has our own idea of what 'well as possible' consists of. Some people can't stand pain, some can't stand nausea. Some want to travel, some want to garden. Which treatment you choose depends on these goals.

Oncologists like to start with the treatments with the fewest side-effects and work their way in. To me that makes total sense. Once one treatment fails, you move on to the next and so on until one or more of your organs starts to fail.

The science shows that letrozole plus palbo works better then letrozole alone. It holds off progression, but has not shown a survival advantage. The older studies show that letrozole is slightly better than tamoxifen but not as much as the previous paragraph. If you are going to MD Anderson, ask them to give you the abstracts with the actual numbers. If you PM me I can find them for you.

Still with me?

I see your choices are: (1) tamoxifen, then when that fails letrozole or letrozole plus palbo. When that fails, Faslodex or Faslodex plus Ibrance.

(2) skip the tamoxifen and start with letrozole plus palbo. If you're going to skip tamoxifen you should go whole hog.

As for ovarian suppression, has the Taxol stopped your periods? You can have a test done to be sure your ovaries are not putting out estrogen. If your periods have stopped, the moment they start again you need ovarian suppression. If you want to be sure, just have them out. It's an easy day surgery. Tamoxifen will not suppress your ovaries. It blocks estrogen from getting to the cancer cells, but you want as little for it to do as possible.

Looking for a recommendation? I don't really have one. I personally did a form of (1). Took tamoxifen for three years before the cancer started growing. But (2) is totally reasonable. It's considered standard of care at the big cancer centers these days (I go to a big cancer center myself).

cive · July 2017

Helen, pajim's explanation is great. It is also treating cancer for progression free survival as opposed to overall survival although they can be almost the same. You start with little guns keeping as much quality of life as possible and when it starts to not delay progression, you move on to a bigger gun. I started with letrozole alone and then when we saw progression after 18 good months on letrozole, I've graduated to faslodex, which although not an AI suppresses estrogen production, and Ibrance (palbociclib). If you get good progression free survival many times, that can be a pretty good overall survival.

Hopefulgirl · July 2017

great explanation PAjim and Clive I just happened on this post and had the same question.

I just started Ibrance and letrozole on Thursday. how long do people typically stay on ibrance? I am assuming for as long as u are tolerating and without progression?

And is it at all possible that I see slight improvement in sternum mets. Less pain? I feel foolish saying same after only taking 2 ibrance pills and 3 letrozole?

Letrozole and Ibrance

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