Breast cancer

NEW --- CDK4/6 inhibitors for everyone? First-line treatment strategies in HR+ HER2- MBC

Laurence (67 years old)

Laurence, a 67-year-old woman, fell on her back during a walk. An X-ray showed several suspicious lesions in the spine and iliac bone. A further diagnostic workup was performed, which revealed ER+ HER2- MBC. She started a first-line treatment with ribociclib and letrozole, with partial response at the first disease re-evaluation. Four months after the start of the treatment, she presents with a severe increase (grade 4) of the transaminases.

Assessment summary:

Postmenopausal
No relevant symptoms/signs
ECOG PS: 0
Haematology and biochemistry: all values normal except AST and ALT >20x ULN
Imaging:
- No liver metastases
- Lesions in spine and iliac bone: partial response
- Breast cancer lesions in response to treatment
Serology for hepatitis viruses, CMV, EBV: negative
Serology for autoimmune hepatitis: negative
Hepatologist consultation: likely drug-induced liver injury

Which option would you choose for this patient?

Permanently discontinue both ribociclib and letrozole

Permanently discontinue ribociclib and continue letrozole alone

Permanently discontinue ribociclib, continue letrozole, and consider to start palbociclib or abemaciclib when transaminases are back to normal values

Withhold ribociclib, continue letrozole, and consider to re-start ribociclib when transaminases are back to normal values