Metastatic hormone receptor-positive breast cancer: palbociclib and fulvestrant during dialysis

What happened, in summary

This 62-year-old woman had end-stage renal disease from IgA nephropathy and had been receiving hemodialysis 3 times per week for 10 years when metastatic breast cancer treatment required special planning. Her original breast cancer was pT1cN2M0, Stage IIA. The tumor was ER-positive by Allred score 7+, PR-negative, HER2 0 / HER2-negative, and Ki-67 was 20.1%. She first had breast-conserving surgery, then adjuvant radiotherapy to the chest wall and letrozole. Sixty months after surgery, CT and PET-CT showed metastatic recurrence with a right upper-lobe lung nodule, pleural dissemination, bone metastasis, and right supraclavicular lymph-node enlargement. Two months later, she started fulvestrant injections plus oral palbociclib. Because there was limited safety information for palbociclib in patients with end-stage renal disease on hemodialysis, the starting dose was reduced to 100 mg/day rather than the standard 125 mg/day. Early treatment caused grade 3 leukopenia, neutropenia, and thrombocytopenia, plus anemia, fatigue, and nausea, so palbociclib and fulvestrant were briefly stopped. Fulvestrant resumed first, and palbociclib was restarted at 75 mg/day, then later reduced to 50 mg/day after recurrent blood-count toxicity. She also required red-cell transfusion for grade 3 anemia. Drug monitoring showed palbociclib and fulvestrant were not removed by hemodialysis. As of August 2025, CT scans showed no disease progression, with stable metastatic breast cancer for 18 months on carefully adjusted therapy. The case is notable because treatment was not withheld simply because she was on dialysis; instead, her team used lower starting doses, close toxicity monitoring, drug-concentration testing, and stepwise dose reduction to keep standard metastatic breast cancer therapy feasible.