Breast CA antihormones, concurrent vs sequential

[IonsAreOurFuture]

I have a patient with very poor health who cannot medically undergo surgery - heart failure, O2 dependent - but we are treating a bulky breast mass about 7 cm in size and grossly involved regional nodes.

ER is 90 plus percent positive, so she will be getting anti estrogens of some kind; the question is whether to give the radiation and anti hormones together or sequentially. Is there any data either way?

I believe there was a breast chemo study that showed better response rate if the antihormones were sequential instead of concurrent, they suggested that maybe chemo works better if growth/mitosis was not hormonally suppressed.

Any breast radiation data though?

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[TheWallnerus]

I would start the hormone therapy first, and if it’s working “ride that” for several months. Can get some pretty great responses. Then irradiate. And I would just treat while on the anti-estrogen. The data is pretty weak that it’s “wrong.” None of the studies are that compelling one way or the other.

 

[evilbooyaa]

Agree, cytoreduce with systemic therapy before you attempt to give definitive RT. I mean, Letrozole/Ibrance is first line for ER+ metastatic patients - could she be eligible to start on that until 'maximally' cytoreduced?

 

[IonsAreOurFuture]

Excellent advice and I really appreciate it. One reason why I wanted to start with radiation though, is that I think the bulk would respond really well to GRID plus some regular EBRT.

I've treated half a dozen or so gigantic tumor with it and the results are well beyond my expectations, like a 12 cm lung or breast mass that was gone in 3 months without chemo.

Only downside to starting with drug therapy is the target may get too small for GRID to be feasible, not that that's wrong, but it removes the potential GRID-induced immune response from the repertoire.

 

[thecarbonionangle]

Excellent advice and I really appreciate it. One reason why I wanted to start with radiation though, is that I think the bulk would respond really well to GRID plus some regular EBRT.

I've treated half a dozen or so gigantic tumor with it and the results are well beyond my expectations, like a 12 cm lung or breast mass that was gone in 3 months without chemo.

Only downside to starting with drug therapy is the target may get too small for GRID to be feasible, not that that's wrong, but it removes the potential GRID-induced immune response from the repertoire.

Are you doing virtual grid with protons or a physical photon add on block? 15 x1? What dose?

 

[TheWallnerus]

Excellent advice and I really appreciate it. One reason why I wanted to start with radiation though, is that I think the bulk would respond really well to GRID plus some regular EBRT.

I've treated half a dozen or so gigantic tumor with it and the results are well beyond my expectations, like a 12 cm lung or breast mass that was gone in 3 months without chemo.

Only downside to starting with drug therapy is the target may get too small for GRID to be feasible, not that that's wrong, but it removes the potential GRID-induced immune response from the repertoire.

For my money, you’re thinking too hard. I just don’t think radiotherapy is going to be the full savior here. Especially relying on the patient’s immune response to “exotic” (not pejorative) radiotherapy approaches. I would think we want the downside (logs less tumor cells) you mention. Sounds like a great upside.

 

[evilbooyaa]

Agree with the Wallnerus. GRID is a valuable tool and certainly has potential to become more mainstream down the line, but I think at the current evidence base, it should be used when there are no other options available to the patient, not as a 'first-line' therapy. Omitting the concept of downstaging a patient simply because you want to GRID them does not compute in my brain.

 

[sirspamalot]

GRID is the last thing I'd consider before hormonal, immuno, and generalized palliative radiotherapy.

 

[deleted1111261]

There is no surgery taking place

We are in no man’s land

This is an option.

Who knows what is optimal ?

There was a recent sbrt breast study showing how much volume loss of tumor occurs etc. i think that’s an option, too.

I’d probably just do ET until it stopped working then 26/5