Hormone Therapy in Patients with HR+/HER2- Metastatic Breast Cancer

Ryan Haumschild, PharmD, MS, MBA: Referencing what Dr Moore mentioned, there are treatments not only [for] CDK4/6, but [there is] also endocrine therapy we’re looking at. Dr DiMarco, could you talk to us about the role of hormonal therapy [in] patients [with] HR+/HER2– metastatic breast cancer and go through some of the key adverse effects that pharmacists would want to monitor in these patients?

Rose DiMarco, PharmD, BCPS, BCOP: Hormone therapy is incredibly important in these patients. They’re hormone-positive cancers. They’re driven by hormones. We need to block those. And that’s why we give hormone therapy in combination with the CDK4/6 inhibitors. Something that comes up for me a lot in clinic is that we have to assess the menopausal status before we prescribe anything. Dr Kettle mentioned earlier [that] patients are getting [diagnoses at] earlier ages, so we might have some premenopausal patients who need to be treated for metastatic cancer. So we have to make sure there’re on a variant suppression in combination with their endocrine therapy. And that compounds the adverse effects or the adverse effects of menopause: hot flashes, night sweats. And it’s easy for people to [say], “It’s not chemotherapy, so it’s tolerable.” But these adverse effects are hard, and the patients have a difficult time. And that’s not even counting the CDK4/6 adverse effects. Hot flashes and night sweats can be managed with nonpharmacological strategies. And that’s a lot of what I recommend in clinic. But sometimes we need to bring in some prescription medications to help with that. There’s vaginal dryness, which no one talks about it, but it can really [affect] patients’ quality of life, their relationships, and how they feel about themselves. So we need to bring that up. I always include that in my education, and sometimes people get itchy about it. But it is something that needs to be talked about, and we need to help them through that. [Two] of the most difficult adverse effects are myalgia and arthralgia, and the best thing that you can do for [them] is to exercise. But it’s easy enough for me to say, “Go out and take a walk.” But sometimes patients don’t live in areas where you can safely walk. They don’t have sidewalks; they don’t have safe parks where they can exercise or [have] access [to] gyms. So that’s stuff that we need to think about when we’re prescribing these medications. Organizations [such as] Livestrong and Living Beyond Breast Cancer are helpful here because not only can they hook the patients up with support groups that can work through some of these [challenges], but they can give them exercise programs for free. That really helps with other adverse effects [such as] fatigue, which is almost impossible to [manage]. And they can be difficult medications. We have to worry about their bone density. We have to check their DEXA [dual-energy x-ray absorptiometry] scans. It’s always me prescribing calcium and vitamin D in clinic because everybody forgets it, and it’s a lot to monitor and manage for pharmacists. That’s why we’re so important in clinic.

Ryan Haumschild, PharmD, MS, MBA: If a patient isn’t being educated on these things on the front end, they could sometimes get discouraged or [say], “I’m having adverse effects that I’m not prepared for. I’m going to stop taking this therapy.” But the more that we have those pharmacies and clinics that are talking about these adverse effects on the front end, [the better]: “Here’s what you’re going to do. Here’s what you’re going to expect.” A lot of our pharmacists, either through…practice agreements or certified pharmacy practitioners [such as those] in North Carolina, are able to do prescribing, and they’re selecting a lot of these agents and selecting a lot of supportive care. And [as] you mentioned in your practice, what a key role that is, now more than ever before, with a multidisciplinary team where pharmacists are key decision makers not only in the treatments but in the adverse effect management. And the great thing is [that] the patients benefit.

Transcript is AI generated and edited for clarity and readability.