Anemia of Unknown Origin in an 80-Year-Old Woman

Kathy D. Miller, MD; Jill Kremer, MD


July 30, 2015

Late recurrence (> 5 years after initial diagnosis) is common in hormone-sensitive breast cancer, with more than half of all recurrences detected after year 5. Metastatic breast cancer is not curable with any standard therapy or known investigational approach. In this situation, the most important goal is to help patients live as well as possible for as long as possible. That always requires negotiating a sometimes difficult balance between maximizing control of the disease while minimizing toxicity of therapy at the same time.

A meta-analysis of eight small randomized trials comparing the response rates for chemotherapy with the response rate for endocrine therapy found an advantage for chemotherapy (relative risk, 1.25; 95% confidence interval, 1.01-1.54).[3] However, these trials were all published prior to 1995 and many of the trials enrolled patients with unknown estrogen receptor status. Because hormone therapy would not be expected to have any benefit in patients with estrogen receptor-negative tumors, these trials would be predicted to underestimate the benefit of hormone therapy.

Initial chemotherapy is a reasonable option in patients with estrogen receptor‒positive disease who have visceral crisis (defined as end-organ dysfunction, not the mere presence of visceral disease) or rapidly developing symptoms. This patient's initial breast cancer had lobular histology and was strongly estrogen receptor‒positive; continuous expression of the estrogen receptor was confirmed in the metastatic disease in her bone marrow. She had a long disease-free interval and had few symptoms of her disease. All of these features point to a recommendation for additional hormone therapy rather than an immediate move to cytotoxic chemotherapy.


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