Treatment of the jaundiced patient with breast carcinoma - Case report andalternate therapeutic strategies

BACKGROUND. Breast carcinoma in the setting of liver metastases and jaundic e raises a complex therapeutic dilemma. Not only is the prognosis poor but toxicity related to treatment can be unpredictable due to altered drug clea rance. Guidelines built around dose reduction have been suggested but often do not address the varied presentations in clinical medicine. Bilirubin ex ceeding 5.0 mg% often is considered an absolute contraindication to the adm inistration of chemotherapeutic agents dependent on hepatic metabolism. METHODS. A 55-year-old woman with metastatic breast carcinoma to the liver and hyperbilirubinemia was treated with sequential, empiric chemotherapy ag ents with the goal of preventing severe toxicity through dose reduction, av oidance of combination therapy, divided doses (weekly therapy), and selecti on of drugs less dependent on hepatic clearance. Several attempts did not y ield a regimen with a successful response, but toxicity was minimal. Eventu ally, a successful schedule and dose of an agent cleared by liver metabolis m was individualized for the patient. RESULTS. After eight cycles of low dose weekly doxorubicin chemotherapy, th e patient's symptoms resolved, bilirubin level normalized, and performance status returned to baseline. The patient remained on treatment and was aliv e 12 months later. CONCLUSIONS. The authors propose that altering a drug schedule by dividing doses may minimize toxicity, maintain dose intensity, and represent an alte rnative strategy far the treatment of patients with hepatic impairment. (C) 2001 American Cancer Society.