How would you manage a young patient with newly recurrent metastatic triple negative breast cancer less than a year after completing adjuvant chemotherapy and worsening liver function due to intrahepatic disease?

Since she has a DFI less than 1 year from last taxane exposure, I would consider her taxane resistant. In general, I try to do carboplatin/gemcitabine, especially if the LFTs are abnormal. If her PDL1 is positive, you can try to add pembrolizumab similar to the KEYNOTE355 regimen. Following this other standard of care, agents can include eribulin, and now sacituzumab, depending on how bad her liver dysfunction is. Clinical trials should always be looked at and prioritized if possible, but many front line trials restrict entry for women with short DFIs. NGS is good to do, but I have found many of these aggressive recurrences have tough to target abnormalities like p53 mutations and MYC amplifications.

The choice of the regimen depends on the extent of the abnormalities of LFT, and also there is a need for the speed of the timeframe of the LFT changes before one can decide the regimen. Nab-paclitaxel, vinca alkaloids, and eribulin will all need a dose adjustment if the LFT is going up. But it can be a choice.

Gemcitabine and carboplatin or gemcitabine alone are choices if the patient has a good performance status and high LFTs. Gemcitabine may not need an adjustment unless with very high bilirubin.

Either way, there is a need for a discussion with a clinical pharmacist before you dose the patient.