60 year female with history of an inflammatory Stage IIIb ER+/HER2 neg breast cancer in 2020. Received neoadjuvant chemotherapy then left modified radical mastectomy, pathology showed ypT0N1a. She then had adjuvant RT to chest wall and lymphatics, then her oncologist at the time gave her capecitibine for 4 months (note sure why), before she was started on tamoxifen (due to osteopenia at the time). She presented to my clinic a couple of weeks ago with new diffuse hepatic mets and left supraclavicular metastases. She is pending a biopsy to confirm cancer type and hormone profile. Given her extent of new disease, I am consider starting chemotherapy due to visceral crisis (diffuse liver involvement and dysfunction). My question is if she has good response, is it appropriate to switch her back to endocrine therapy after she receives chemo, or should I continue with the chemo until progression of disease or unacceptable toxicity.
I totally agree with initial chemotherapy for true visceral crisis, and I think it would be very appropriate to transition to endocrine-based treatment (AI and CDK4/6i) once an adequate response is seen. I don't think you necessarily need to continue chemotherapy until progression/toxicity. With the PFS/OS benefits seen with CDK4/6i (and good tolerance), I think getting her out of her crisis with chemotherapy, then transition to AI/CDK is an excellent idea. Based on Right Choice trial, if only mild liver dysfunction, you could consider starting with AI/CDK, but if true visceral crisis chemotherapy is standard.
