Value-Based Decision-Making in Metastatic Breast Cancer - Episode 10
Debra Patt, MD, PhD, MBA, explains how clinical practice has adapted to the use of targeted therapies to treat HER2-positive metastatic breast cancer.
Briana Contreras: How have you changed your practice to accommodate patients on targeted therapy in terms of patient care?
Debra Patt, MD, PhD, MBA: We frequently see these patients in intervals when they receive treatment. So, if we see these patients every 3 weeks, frequently they require regular follow-up with echocardiograms to evaluate their cardiac function, as many HER2 [human epithelial growth factor receptor 2] targeted agents have an infrequent side effect of cardiac toxicity. Other toxicities need to be managed if they’re just on a nonchemotherapy-based regimen that has HER2 blockade and endocrine therapy. Frequently, they have to be seen even less by providers, once doctors or advanced practice providers that work with us can establish that they’re tolerating their treatment without significant side effects.
Briana Contreras: What have been some of the challenges, and can you include both clinical and nonclinical factors?
Debra Patt, MD, PhD, MBA: Some challenges in this patient population are some of the adverse events that we see. If you see that someone has cardiac morbidity related to infusion of HER2 targeted therapy, that needs to be managed appropriately. We’re very fortunate here to work with a cardiologist that really is an onco-cardiology expert. We’ve been very successful in referring patients, treating them on cardiac remodeling drugs like carvedilol, and then retreating them with HER2 blockade safely and effectively. So, while that’s an infrequent complication, because I have many patients with HER2-positive metastatic breast cancer I have seen some of it and have been very successful in patients continuing their remission despite these toxicities, because we can manage them well in collaboration with our cardiology partners and get patients back on effective therapy. So that’s been really encouraging. The other complication that’s challenging for providers and patients is that this patient population has a higher predilection for brain metastasis and managing brain metastases is complex. It used to be, 15 years ago, that frequently we would have these patients undergo whole brain radiation therapy whenever they had brain metastasis, because the long-term supply of whole brain radiation therapy wouldn’t manifest for many years. Generally, patients with breast cancer that had metastasized to the brain did not survive long enough to realize some of those long-term toxicities. That’s no longer the case in this patient population because we’ve had tremendous positive disruption because of innovation, and therapeutic interventions that cross the blood brain barrier. We’re very effective at controlling this patient population. I personally have many patients in my practice who had brain metastases more than a decade ago. They continue to live well, without any progression of their disease. They continue to work in their jobs. So, figuring out how frequently to look in the brain is always tricky in this patient population. The standard of care would suggest that we only look when patients have symptoms. But in my experience, patients can have some mild symptoms of mild lethargy, or could have focal neurologic deficits that leads you to image their brain. Imaging the brain is important because HER2 disease has such a predilection for the central nervous system that you need to work in collaboration with a multidisciplinary team to understand what exactly the best way is to manage this for the patient. Sometimes it might require surgery for the patient, which would involve a neurosurgeon. Frequently, it involves collaboration with a radiation oncologist that can give targeted therapy to the patient. Usually, it is combined with some sort of systemic treatment change to make sure that we’re giving a therapy that’s highly effective in controlling disease and the central nervous system. Many of these patients will go on later to develop other central nervous system metastasis. How we approach this each time is really a multidisciplinary treatment decision. So having a good multidisciplinary team can be really important in helping you navigate this complicated space.
Briana Contreras: What have been the implications of these changes or challenges for your practice in terms of resource utilization?
Debra Patt, MD, PhD, MBA: Frequently, when we have patients with cardiac complications or brain metastasis, we have weekly multidisciplinary tumor boards where we discuss these patients just for breast cancer. We frequently can benefit from multidisciplinary treatment planning. Well, we don’t bill for that service. Of course, it’s just sort of volunteer time on our part, but we think it’s a good part of patient care. So, it doesn’t directly impact health care resource utilization for the patient, the fact that we have to go through these additional steps, but patients undergoing additional steps of surgery and/or radiation and/or changes to new or novel therapies that may have better penetration of the central nervous system does impact health care resource utilization. Let’s say for example, I had a patient that was on an endocrine blockade and trastuzumab alone, and they had brain metastasis, and I chose to transition them either to ado-trastuzumab or tucatinib in combination with trastuzumab and capecitabine; that would be a higher cost choice, that would increase health care resource utilization, but it would be effective therapy for the patient.
Briana Contreras: Can you share how you have had to educate staff or patients in light of changes in practice, due to the use of targeted therapies?
Debra Patt, MD, PhD, MBA: We have to provide a lot of education. The pace of change in oncology is unprecedented. We have newer drugs all the time, and the advent of targeted therapies and immunotherapies has dramatically changed the field. So, we have to provide a lot of education. We have a lot of informational webinars for our nurses and for our physicians. I do an update here locally after our major conferences, and there are a lot of updates in general from various sources. There are many different ways in which people can sort of ingest the new oncology content. But I feel like once I finished school, I still have homework every night, because cancer care is continuously changing. Again, at a pace that’s unprecedented.
Transcript edited for clarity.