DR VANDERPUYE CONSULTANT RADIATION AND CLINICAL ONCOLOGIST GHANA REVIEW 0F 20 METASTATIC BREAST CANCER CASES RECEIVING CAPECITABINE MONOTHERAPY DR VANDERPUYE CONSULTANT RADIATION AND CLINICAL ONCOLOGIST GHANA

PURPOSE TO EVALUATE THE TIME TO PROGRESSION AND TOXICITY OF TWENTY STAGE 4 BREAST CANCER PATIENTS TREATED WITH CAPECITABINE MONOTHERAPY IN GHANA

Introduction 20- 85% of breast cancer patient→mets in 5 yrs 6- 10% will be diagnosed initially as stage 4 MS of stage 4 is 18- 24 mths traditionally New drugs/ targeted developments →↑ OS QoL is prime consideration in palliative care Even though combination therapy may ↑TTP, RR, but ↑toxicity with little ↑OS benefit International guidelines recommend single agent chemotherapy as a viable option Best combination ≠ best outcome all things considered

Introduction Even for CR response last 8- 14 mths Overall average TTP is 7 months with chemo Remember progression is inevitable Drugs used as 2ND line are tax, gem, cape, vinorelbine, anthracylines etc Xeloda with other drugs ↑benefits no doubt Comparatively cape citabine monotherapy ↓ lowest toxicity even at reduced doses For low resource setting finance is #1!! Creating the fine balance b/n QoL & outcome can be problematic!!

MATERIALS AND METHODS 20 Patients diagnosed With Metastatic Breast Cancer 2000- 2007 PS ECOG < 3 Patients With No Prior Chemotherapy Were NOT Allowed All Had Capecitabine As Monotherapy In Metastatic State Parameters Assessed Include Age Initial Chemotherapy Site Of Recurrence Dose Of Capecitabine Toxicity Time To Progression

RESULTS Age Range : 25 – 84 Yrs Median Age: 46yrs Followup Range: 1 – 40 Mths Median Followup: 6 Mths Mean Followup Time: 20mths # Sites Involved 1 Site (9) 2 Sites (7) >2 Sites ( 4)

RESULTS CAPECITABINE PER LINE OF TX Prior Chemotherapy: Adjuvant Anthracycline 12 Taxane/Anth 3 2nd Line Taxane 9 Dose Of Capecitabine: 2000-2500mg/M2 16/20@ 2000mg/M2 # Of Capecitabine Cycles: 3-18 Mean # Cycles: 6 3/20 Dose Reductions After ≥4cycles (2 @ 2500mg/M2)

RESULTS Time To Progression(TTP) Range: 3 – 44 Months Median Overall TTP: 6 Mths Median TTP For Brain (X Only) :4mths ( 4- 9mths) Median TTP For Brain (X +Rt) :24mths (4- 38 Mths) Median TTP Per Line Of Tx 2nd Line :11 Mths ( 3 – 27mths) 3rd Line : 6 Mths ( 3- 10mths) 4th Line : 5 Mths ( 3- 7mths)

TOXICITY PROFILE Diarrhoea & vomiting Hand & Foot Haematological     Diarrhoea & vomiting Hand & Foot Haematological Mucositis Grade 1 1 Grade 2 Grade 3 Grade 4

DISCUSSION Literature summary of RR of single agents Docetaxel 27% 72% Febrile Neutropenia! Vinorelbine 25% 58% G 3/4 Neutropenia Gemcitabine 0% Myelosupression Capecitabine 20% H&F , D&V Capecitabine @ 2500mg/m2⇒ D & V Interruptions(56%) ↑G 3 H&f (30%) ⇒Stop!( 17%) Capecitabine @ 2000mg/ m2 ⇨ more tolerable less H&F less interruptions

DISCUSSION Compared to other single agents , toxicity very manageable especially at lower than recommended doses supported by numerous data(>8) without compromising outcome Fewer dose reductions/ interruptions with 2000mg/m2 Oral adminstration a big plus for QOL, patient resources ie adjuvants, staffing, Even as 2, 3 th line acceptable alternative Best results in TTP when with RT for brain mets! Temozolamide with RT the only recommended choice but maybe a new paradigm

DISCUSSION Monotherapy Capecitabine TTP 4.2 MTHS When given as combination What does 2 mths benefit mean to US? ( toxicity, finances) No compelling evidence that combination tx better Combination TTP ( MTHS) X + CISPLATIN 6.3 X + DOCETAXEL 6.1 X + IXAPETHILONE 5.8 X+ BEVICUCIMAB 4.0

CONCLUSION Recommend Capecitabine for metastatic breast ca In low resource setting as mono- or combination tx Prefarably for taxane and anthracycline resistant but taxane not readily available Can be used as 2nd , 3rd or more Tolerable @2000mg/m2 without compromise and reduces cost. Further investigation for brain RT+ capecitabine!!

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