Table 1.

Summary of assessments and clinical decisions

Time frame	Clinical decision	Assessments	Commentary
November 2006	Therapy switch to fulvestrant plus zoledronic acid	Imaging – PD	– Decision to switch therapy based on imaging that showed PD in November 2006
		[CTC] – low
July 2007	Continuation of fulvestrant plus zoledronic acid treatment	Imaging – PR	– Marginal [CTC] agreed with good performance status
		Clinical – performance status: good
		[CTC] – marginal	– Continued fulvestrant plus zoledronic acid therapy
		[CEA] – elevated, stable
		[CA 27.29] – elevated, stable	– Imaging showed equivocal response
December 2007	Continuation of fulvestrant plus zoledronic acid treatment	Imaging – MR	– Imaging response, performance status, and absence of CTCs indicate good prognosis
		Clinical – performance status: good
		[CTC] – absent
		[CEA] – elevated, stable	– Continued treatment
		[CA 27.29] – elevated
February 2008	Continuation of fulvestrant plus zoledronic acid treatment	Clinical – performance status: reporting increasing pain	– Clinical symptoms and increased [CTC] suggest progression
		[CTC] – low
		[CEA] – elevated, stable	– Treated with radiation
		[CA 27.29] – increasing
May 2008	Therapy switch to Abraxane plus bevacizumab	Imaging – PD	– All assessments suggesting progression
		[CTC] – elevated
		[CEA] – elevated	– Therapy switched to Abraxane plus bevacizumab
		[CA 27.29] – elevated
August 2008	Discontinue bevacizumab	Clinical – ulceration on foot	– Stably absent CTCs agree with prior PR on imaging
		[CTC] – absent
			– Bevacizumab discontinued to address treatment-related AEs
September 2008	Discontinue Abraxane	Clinical – neuropathy	– Continued absence of CTCs
		[CTC] – stably absent	– Drug holiday to address treatment-related AEs

PD = Progressive disease; PR = partial response; MR = mixed response; [CTC] = CTC concentration; [CEA] = CEA concentration; [CA 27.29] = CA 27.29 concentration; AE = adverse effect.